2023

Care of Clients with Problems with Life

threatening Conditions, Acutely
Ill/Multi-organ Problem, High Acuity &
Emergency

Lecture

Transcripted by
Cruz, Larraine Jhasmine D.
cruz2002012@ceu.edu.ph
 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

Gastrointestinal Alterations
Overview of the System
The major function of the gastrointestinal (GI) tract is
digestion, which is the conversion of ingested nutrients into
simpler forms that can be transported from the lumen of the
GI tract to the portal circulation and then used in metabolic
processes. The GI system also plays a vital role in the
detoxification and elimination of bacteria, viruses, chemical
toxins, and medications. Disturbances of the GI system itself
or of the complex hormonal and neural controls that regulate
the GI tract can severely upset homeostasis and compromise
the overall nutritional status of the patient. Any
circumvention of the normal feeding mechanism can alter
digestive processes or contribute to malabsorption. A critical
care nurse must have a comprehensive knowledge of the
anatomy and normal function of the GI tract to facilitate
assessment, diagnosis, and intervention in patients with GI
dysfunction. The GI tract consists of the mouth, esophagus,
stomach, small intestine, and large intestine.

The digestive hormones are not secreted into the GI lumen

but rather into the bloodstream, in which they travel to target
tissues. There are more than 30 peptide hormone genes
expressed in the GI tract and more than 100 hormonally
active peptides.

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2
Gastric Secretion
The stomach has two types of glands, oxyntic (also known
as gastric glands) and pyloric, that contain cells of various
types that secrete 1500 to 2400 mL/day of gastric juice into
the lumen, depending on the diet and other stimuli. Gastric
juice is composed of hydrochloric acid, pepsin (necessary
for the breakdown of protein), mucus, intrinsic factor
(necessary for vitamin B12 absorption), sodium, and
potassium. Pepsinogen, secreted by the chief cells of the
stomach lining, is converted to its active form, pepsin, in the
acidic environment of the stomach. The cardiac glands
secrete mucus and pepsinogen. The oxyntic glands contain
parietal cells, which secrete hydrochloric acid and intrinsic
factor, and chief cells, which secrete pepsinogen. Pyloric
glands contain mucous cells, which secrete mucus and
pepsinogen, and G cells, which secrete gastrin. Gastric
Digestion Process
glands are stimulated by the parasympathetic pathway and
gastrin and inhibited by gastric inhibitory peptide and
enterogastrone. Histamine and entero-oxyntin also stimulate
the parietal cells to produce acid, and secretin stimulates the
chief cells to produce pepsinogen.1 The pH of gastric juice
is 1.0, but when mixed with food, the pH rises to 2.0 to 3.0.
Gastric juice dissolves soluble foods and has bacteriostatic
action against swallowed microorganisms. The composition
of gastric secretions depends on a variety of factors,
including flow rate, volume, and the time of day. Pain, fear,
or rage can inhibit gastric secretion, whereas aggression or
hostility can stimulate gastric secretion.
Gastric Motility
The functions of the stomach include food storage,
digestion, and emptying. The stomach receives food through
the lower esophageal sphincter, stores it for a period, and
then mixes the food with gastric secretions. The food is then
ground into a semifluid consistency called chyme, which is
delivered through the pylorus to the duodenum. Gastric
motility is regulated by the autonomic nervous system,
digestive hormones, and neural reflexes. Gastrin, motilin,
and parasympathetic stimulation increase gastric motility,
whereas secretin, cholecystokinin, enterogastrone, gastric
inhibitory peptide, and sympathetic stimulation decrease
gastric motility. The ileogastric reflex inhibits gastric
motility when the ileum is distended.

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

● Gastric motility is regulated by the autonomic

nervous system, digestive hormones, and neural
reflexes.
● The functions of the small intestine include
digestion and absorption.
● Intestinal motility consists of peristalsis and
haustral segmentation.
● The major functions of the colon include
resorption of water, sodium, chloride, glucose,
and urea; dehydration of undigested residue;
putrefaction of contents by bacteria; movement
of the fecal bolus through the colon; and
elimination of the fecal mass.
● Colonic motility consists of haustral shuttling
and peristalsis.
● The functions of the liver include metabolism
Accessory Organs and storage of carbohydrates, fats, proteins, and
vitamins; synthesis of plasma proteins;
detoxification of drugs and toxins; and
production of bile.
● The main functions of the gallbladder are to
collect, concentrate, acidify, and store bile.
● The main functions of the pancreas are digestion
and glucose regulation.

Assessment and Diagnostics

Assessment of a critically ill patient with gastrointestinal
(GI) dysfunction includes a review of the patient’s history, a
focused physical assessment, and analysis of the patient’s
laboratory data. Numerous invasive and noninvasive
diagnostic procedures may also be performed to identify the
disorder. A thorough assessment of a patient with GI
dysfunction is imperative for early identification and
treatment of GI disorders. This chapter focuses on clinical
assessments, laboratory studies, and diagnostic procedures
for critically ill patients with gastrointestinal dysfunction.

Key Points
Anatomy
● The GI tract consists of the mouth (lips, cheeks,
gums, tongue, palate, and salivary glands),
esophagus, stomach, small intestine, and large
intestine.
● The accessory organs of digestion are the liver,
biliary system, and pancreas.
Physiology
● The major function of the GI tract is digestion.
● Digestion is the conversion of ingested nutrients
into simpler forms that can be transported from
the lumen of the GI tract to the portal circulation
and then used in metabolic processes.
● The mouth and accessory organs perform the
initial phases of digestion, which are ingestion,
mastication, and salivation.
● The functions of the stomach include food
storage, digestion, and emptying.

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2
Focused Physical Exmaination
bruits. Auscultation of the abdomen provides clinical
Mnemonic: data regarding the status of bowel motility. Initially, listen
OA si PEPA (OAPEPA) with the diaphragm of the stethoscope below and to the
right of the umbilicus. The examination proceeds
● Observation/inspection methodically through all four quadrants, lifting and then
● Ascultation replacing the diaphragm of the stethoscope lightly against
● Percussion the abdomen.
● Palpation
The rationale is to ensure that there
will be no false results that may be
caused by peristalsis and
alterations.

Observation or inspection
Inspection of the patient focuses on three areas: (1)
observation of the oral cavity, (2) assessment of the
skin over the abdomen, and (3) evaluation of the
shape of the abdomen. Inspection should be performed
in a warm, well-lit environment, and the patient should be
in a comfortable position, with the abdomen exposed.
● Observation of the Oral Cavity
Although assessment of the GI system classically begins
with inspection of the abdomen, the patient’s oral cavity
also must be inspected to determine any unusual findings.
Abnormal findings of the mouth include
temporomandibular joint tenderness, inflammation of
gums, missing teeth, dental caries, ill-fitting dentures, and
mouth odor.
● Assessment of the Skin Over the Abdomen
Observe the skin for pigmentation, lesions, striae, scars, Normal bowel sounds include high-pitched, gurgling
petechiae, signs of dehydration, and venous pattern. sounds that occur approximately every 5 to 10 seconds5
Pigmentation may vary considerably and still be within or at a rate of 5 to 30 times per minute. Colonic sounds
normal limits because of race and ethnic background, are low-pitched sounds with a rumbling quality.
although the abdomen usually is of a lighter color than Abnormal findings include the absence of bowel sounds
other exposed areas of the skin. Abnormal findings throughout a 5-minute period; extremely soft, widely
include jaundice, skin lesions, and a tense and glistening separated sounds; and increased sounds with a
appearance of the skin. A deviated umbilicus may be high-pitched, loud rushing sound (peristaltic rush).
caused by a mass, hernia, fluid, or old scar tissue. An Hyperactive bowel sounds that are tinkling may indicate
everted umbilicus is apparent with distention. Old striae increased motility related to an early bowel obstruction,
(stretch marks) usually are silver, whereas pinkish purple diarrhea, or gastroenteritis. Hypoactive bowel sounds
striae may indicate Cushing syndrome. Bluish may indicate paralytic ileus after surgery, which is very
discoloration of the umbilicus (Cullen sign) and of the common; peritoneal irritation; or bowel obstruction.
flank (Grey Turner sign) indicates retroperitoneal Absent bowel sounds may result from inflammation;
bleeding. ileus; electrolyte disturbances; and ischemia, which
● Evaluation of the Shape of the Abdomen requires immediate attention
Observe the abdomen for contour, noting whether it is
flat, slightly concave, or slightly round; observe for
symmetry and for movement.6 Marked distention is an
abnormal finding. Ascites may cause generalized
distention and bulging flanks. Asymmetric distention may
indicate organ enlargement, large masses, hernia, or
bowel obstruction.5 Peristaltic waves should not be
visible except in very thin patients. In the case of
intestinal obstruction, hyperactive peristaltic waves may
be observed. Pulsation in the epigastric area is often a
normal finding, but increased pulsation may indicate an
aortic aneurysm.6 Symmetric movement of the abdomen
with respirations is usually seen in men
Auscultation
Auscultation of the patient focuses on two areas: (1)
evaluation of bowel sounds and (2) assessment of

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

abdominal masses. Areas in which the patient complains

of tenderness should be palpated last.

Percussion
Percussion of the patient focuses on one area: assessment
of the deep organs. Percussion is used to elicit
information about deep organs such as the liver, spleen,
and pancreas. Because the abdomen is a sensitive area,
muscle tension may interfere with this part of the
assessment. Percussion often helps relax tense muscles,
and it is performed before palpation. Percussion in the
absence of disease helps delineate the position and size of
the liver and spleen, and it assists in the detection of fluid,
gaseous distention, and masses in the abdomen.
Percussion should proceed systematically and lightly in
all four quadrants. Normal findings include tympany over
the empty stomach, tympany or hyperresonance over the
intestine, and dullness over the liver and spleen.
Abnormal areas of dullness may indicate an underlying
mass. Tenderness over the liver may indicate
inflammation or infection. Solid masses, enlarged organs,
and a distended bladder also produce areas of dullness.
Dullness over both flanks may indicate ascites and
necessitates further assessment

Laboratory and Diagnostic Procedures

The value of various laboratory studies used to diagnose and
treat diseases of the GI system has been emphasized often.
However, no single study provides an overall picture of the
functional state of the various organs, and no single value is
predictive by itself.

Endoscopy
The top diagnostic procedure for GI alterations
Available in several forms, fiberoptic endoscopy is a
diagnostic procedure for the direct visualization and
evaluation of the GI tract. Endoscopy can provide
information about lesions, mucosal changes, obstructions,
and motility dysfunction, and a biopsy or removal of
Palpation foreign objects may be performed during the procedure.
Palpation of the patient focuses on one area: (1) detection The main difference between the various diagnostic
of abdominal pathologic conditions. Light and deep forms is the length of the anatomic area that can be
palpation of each organ and quadrant should be examined. Esophagogastroduodenoscopy permits
completed. Light palpation, which has a palpation depth viewing of the upper GI tract from the esophagus to the
of approximately 1 cm, assesses to the depth of the skin upper duodenum, and it is used to evaluate sources of
and fascia. Deep palpation assesses the rectus abdominis upper GI bleeding. Colonoscopy permits viewing of the
muscle and is performed bimanually to a depth of 4 to 5 lower GI tract from the rectum to the distal ileum, and it
cm. Deep palpation is most helpful in detecting is used to evaluate sources of lower GI bleeding.

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

Enteroscopy permits viewing of the small bowel beyond

the ligament of Treitz, and it is used to evaluate sources
of GI bleeding that have not been identified previously
with esophagogastroduodenoscopy or colonoscopy.
Endoscopic retrograde cholangiopancreatography enables
viewing of the biliary and pancreatic ducts, and it is used
in the evaluation of pancreatitis. During this procedure,
contrast medium is injected into the ducts through the
endoscope, and radiographs are obtained. Endoscopy also
provides therapeutic benefits for various conditions,
including GI bleeding.

Angiography
Angiography is used as a diagnostic and a therapeutic
procedure. Diagnostically, it is used to evaluate the status
of the GI circulation. Therapeutically, it is used to achieve
transcatheter control of GI bleeding. Angiography may be
used for lower GI bleeding and as a way to isolate the
bleeding source before surgery. Angiography is used in
the diagnosis of upper GI bleeding only when endoscopy
fails, and it is used to treat patients (approximately 15%)
whose GI bleeding is not stopped with medical measures
or endoscopic treatment. Angiography also is used to
evaluate cirrhosis, portal hypertension, intestinal
ischemia, and other vascular abnormalities.
The radiologist cannulates the femoral artery with a
needle and passes a guidewire through it into the aorta.
The needle is removed, and an angiographic catheter is
inserted over the guidewire. The catheter is advanced into
the vessel supplying the portion of the GI tract that is
being studied. After the catheter is in place, contrast
medium is injected, and serial radiographs are obtained.
If the procedure is undertaken to control bleeding,
vasopressin (Pitressin Synthetic) or embolic material
(Gelfoam) is injected after the site of the bleeding is
located.
Nursing Management
Complications include overt and covert bleeding at the
femoral puncture site, neurovascular compromise of the
affected leg, and sensitivity to the contrast medium.
Before the procedure, the patient should be asked about
Nursing Management any sensitivity to contrast medium. Assessment after the
The patient should take nothing by mouth (NPO) for 6 procedure involves monitoring vital signs, observing the
to 12 hours before endoscopy of the upper GI tract. The injection site for bleeding, and assessing neurovascular
patient should receive a bowel preparation before integrity distal to the injection site every 15 minutes for
endoscopy of the lower GI tract. In some cases, the the first 1 to 2 hours. Depending on how the puncture site
procedure is performed at the patient’s bedside, is stabilized after the procedure, the patient may have to
particularly if the patient is actively bleeding and too remain flat in bed for a specified length of time. Any
unstable to be moved to the GI suite. Fiberoptic evidence of bleeding or neurovascular impairment must
endoscopy may present risks for the patient. Although be immediately reported to the physician.
rare, potential complications include perforation of the GI
tract, hemorrhage, aspiration, vasovagal stimulation, and
oversedation. Signs of perforation include abdominal pain
and distention, GI bleeding, and fever.
Example:

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

Plain Abdominal Series

Although numerous radiologic studies are available to
investigate GI dysfunction further, many of these studies
are not performed on critically ill patients because of
hemodynamic instability. The radiologic study that is
performed most often is the plain abdominal series. An
abdominal radiograph is useful in the diagnosis of bowel
obstruction and perforation.Air in the bowel serves as a
contrast medium to aid in the visualization of the bowel.
Gas patterns (the presence of gas inside or outside the
Abdominal Ultrasound bowel lumen and the distribution of gas in dilated and
Abdominal ultrasound is useful in evaluating the status of nondilated bowel) are best revealed by plain radiographs.
the gallbladder and biliary system, the liver, the spleen, Common radiologic signs of free air in the abdomen
and the pancreas. It plays a key role in the diagnosis of include the presence of air on both sides of the bowel
many acute abdominal conditions such as acute wall and the presence of air in the right upper quadrant
cholecystitis and biliary obstructions, because it is anterior to the liver. Free air in the abdomen suggests a
sensitive in detecting obstructive lesions and ascites. perforated bowel, and the need for surgery is paramount.
Ultrasound is used to identify gallstones and hepatic Abdominal radiographs are used to verify nasogastric or
abscesses, candidiasis, and hematomas. Intestinal gas, feeding tube placement.
ascites, and extreme obesity can interfere with
transmission of the sound waves and limit the usefulness
of the procedure. The procedure uses sound waves to
produce echoes that are converted into electrical energy
and transferred to a screen for viewing. A transducer,
which emits and receives sound waves, is moved slowly
over the area of the abdomen being studied. Tissues with
various densities produce different echoes, which
translate into the different structures on the viewing
screen.
Nursing Management
An ultrasound scan can be obtained at the patient’s
bedside using a portable scanning unit. Ultrasound is
easily performed, noninvasive, and well tolerated even by
critically ill patients. The procedure requires only that the
patient lie still for 20 to 30 minutes. No special
interventions are required before or after the procedure.

Nursing Management
An abdominal radiographic series can be obtained at the
patient’s bedside using a portable x-ray machine. The
series includes two views of the abdomen: one in the
supine position and one in the upright position. For

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

patients unable to sit upright, a lateral decubitus patient should maintain NPO status for 6 hours and
radiograph may be obtained with the patient’s left side have blood drawn for coagulation studies. The procedure
down. No special interventions are required before or is performed by anesthetizing the pericapsular tissue,
after the procedure. inserting a coring or suction needle between the eighth
and ninth intercostal space into the liver while the patient
holds his or her breath on exhalation, withdrawing the
Magnetic Resonance Imaging needle with the sample, and applying pressure to stop the
Magnetic Resonance Imaging Magnetic resonance bleeding.
imaging (MRI) is used to identify tumors, abscesses, Nursing Management
hemorrhages, and vascular abnormalities. Small tumors, During liver biopsy, the patient may experience a deep
whose tissue densities are different from those of the pressure sensation or dull pain that radiates to the right
surrounding cells, can be identified before they would be shoulder. After the procedure, the patient is positioned on
visible on any other radiographic test. Magnetic the right side for 2 hours and kept on complete bed rest
resonance angiography is a form of MRI that is used to for the next 6 to 8 hours.Hemorrhage is the major
assess blood vessels and blood flow. complication associated with liver biopsy, although it
occurs in less than 1% of patients. Other complications
include damage to neighboring organs (e.g., kidney, lung,
colon, gallbladder), bile peritonitis, hemothorax, and
infection at the needle site. Puncturing of the gallbladder
can cause leakage of bile into the abdominal cavity,
resulting in peritonitis.

Magnetic resonance cholangiopancreatography is a form

of MRI used to evaluate the biliary and pancreatic ducts.
During MRI, the patient is placed in a large magnetic
field that stimulates the protons of the body. Introduction
of radiofrequency waves causes resonance of these Occult Blood Test
protons, which then emit an image that a computer can The fecal occult blood test (FOBT) is a lab test used to
reconstruct for viewing. Intravenous administration of a check stool samples for hidden (occult) blood.
non iodine-based contrast medium enhances the image by Occult blood in the stool may indicate colon cancer or
influencing the magnetic environment and signal polyps in the colon or rectum — though not all cancers or
intensity polyps bleed.
Nursing Management Typically, occult blood is passed in such small amounts
The MRI procedure is lengthy and requires that the that it can be detected only through the chemicals used in
patient be transported to the scanner. The patient must lie a fecal occult blood test.
motionless in a tight, enclosed space (if a closed MRI ➔ No hematomesis or hematochezia, no occult
scanner is used), and sedation may be necessary. blood test. Question physician if ordered.
Removal of all metal from the patient’s body is essential, ➔ NO BLEEDING=NO OCCULT BLOOD
because the basis of MRI is a magnetic field. Patients TEST
with implanted metal objects are not candidates for the
procedure. No special interventions are required after the
procedure.

Percutaneous Liver
Biopsy Liver biopsy is a diagnostic procedure that is used
to evaluate liver disease. Morphologic, biochemical,
bacteriologic, and immunologic studies are performed on
the tissue sample to diagnose liver disorders such as
cirrhosis, hepatitis, infections, or cancer. A biopsy can Barium Swallow Test
also yield information about the progression of the A barium swallow test (cine esophagram, swallowing
patient’s disease and response to therapy. study, esophagography, modified barium swallow study,
Percutaneous liver biopsy can be performed at the video fluoroscopy swallow study) is a special type of
bedside or in the imaging department and involves the imaging test that uses barium and X-rays to create
use of an imaging-guided needle. Before the test, the images of your upper gastrointestinal (GI) tract. Your

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

upper GI tract includes the back of your mouth and throat

(pharynx) and your esophagus.
Barium is used during a swallowing test to make certain
areas of the body show up more clearly on an X-ray. The
radiologist will be able to see size and shape of the
pharynx and esophagus. He or she will also be able see
how you swallow. These details might not be seen on a
standard X-ray. Barium is used only for imaging tests for
the GI tract.
A barium swallow test may be used by itself or as part of
an upper GI series. This series looks at your esophagus,
stomach, and the first part of the small intestine
(duodenum). Also, fluoroscopy is often used during a
barium swallow test. Fluoroscopy is a kind of X-ray
“movie.”
➔ RED SPOT= POSITIVE
➔ BLUE SPOT= NEGATIVE

Remember:
ALL PATIENTS ARE BOUND TO BE TESTED FOR
GRAM STAINING
➔ VIOLET= POSITIVE

Gastrointestinal Bleeding
GI hemorrhage is a potentially life-threatening emergency
and a common complication of critical illness; it results in
more than 300,000 hospital admissions yearly.1 Despite
advances in medical knowledge and nursing care, the
mortality rate for patients with acute GI bleeding remains at
10% per annum in the United States. GI hemorrhage occurs
from bleeding in the upper or lower GI tract. The ligament
of Treitz is the anatomic division used to differentiate
between the two areas. Bleeding proximal to the ligament is
considered to be from the upper GI tract, and bleeding distal
to the ligament is considered to be from the lower GI tract.

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Cruz, Larraine Jhasmine D.
BSN-4E2
Common Sources of Upper Gastrointestinal Bleeding
Peptic Ulcer Disease (PUD)
● Peptic Ulcer Disease Peptic ulcer disease
○ Gastric ulcer (i.e., gastric and
○ Duodenal Ulcer duodenal ulcers),
● Varices (All due to portal hypertension) which results from
○ Esophageal the breakdown of
■ Confirmatory symptom: the gastromucosal
lining, is the leading
HEMATOMESIS
cause of upper GI
■ No clinical manifestations until hemorrhage,
it exploded (commonly) accounting for
○ Gastric approximately 40%
of cases.
Classifications:
1. Gastric
ulcer. Gastric ulcers tend to occur in the lesser
curvature of the stomach, near the pylorus.
2. Duodenal ulcer. Peptic ulcers are more likely to
occur in the duodenum than in the stomach.
3. Esophageal ulcer. Esophageal ulcers occur as a
result of the backward flow of HCl from the
stomach into the esophagus.

● Pathologies of the Esophagus

○ Tumors
○ Mallory-Weiss
Syndrome
■ Tearing of the
esophagus Normally, protection of the gastric mucosa from the
resulted from digestive effects of gastric secretions is accomplished in
several ways. First, the gastroduodenal mucosa is coated
prolonged and
by a glycoprotein mucous barrier that protects the surface
forceful of the epithelium from hydrogen ions and other noxious
vomiting, substances present in the gut lumen. Adequate gastric
coughing or convulsions. mucosal blood flow is necessary to maintain this mucosal
○ Inflammation barrier function. Second, gastroduodenal epithelial cells
○ Ulcers are protected structurally against damage from acid and
● Pathologies of the Stomach pepsin because they are connected by tight junctions that
help prevent acid penetration. Third, prostaglandins and
○ Cancer
nitric oxide protect the mucosal barrier by stimulating the
○ Erosive gastritis secretion of mucus and bicarbonate and inhibiting the
○ Stress ulcers secretion of acid.
○ Tumors Peptic ulceration occurs when these protective
● Pathologies of the small intestine mechanisms cease to function, allowing gastroduodenal
○ Peptic ulcer mucosal breakdown. After the mucosal lining is
penetrated, gastric secretions autodigest the layers of the
○ Angiodysplasia
stomach or duodenum, leading to injury of the mucosal
and submucosal layers. This results in damaged blood
vessels and subsequent hemorrhage. The two main causes
of disruption of gastroduodenal mucosal resistance are
the bacterial action of Helicobacter pylori and
nonsteroidal antiinflammatory drugs.
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BSN-4E2

● Collapse
● Tender and rigid abdomen
● Hypotension
● Tachycardia
● Sudden abdominal pain
➔ Penetration
◆ Penetration is pathologically similar to
perforation, except that the ulcer does
not erode into the peritoneal cavity, but
into another organ such as the liver or
pancreas
◆ PAIN IS NOT RELIEVED WITH
MEDICATIONS
➔ Hemorrhagic and/or hypovolemic shock
Assessment and Findings
● Esophagogastroduodenoscopy. Confirms the
presence of an ulcer and allows cytologic studies
and biopsy to rule out H. pylori or cancer.
● Physical examination. A physical examination
may reveal pain, epigastric tenderness, or
abdominal distention. (Follow the OA si PEPA
technique)
● Barium study. A barium study of the upper GI
tract may show an ulcer.
● Endoscopy. Endoscopy is the preferred
diagnostic procedure because it allows direct
visualization of inflammatory changes, ulcers,
and lesions.
● Occult blood. Stools may be tested periodically
until they are negative for occult blood.
● Carbon 13 (13C) urea breath test. Reflects
activity of H. pylori.
Medical Management
Clinical Manifestations: ● Pharmacologic therapy. Currently, the most
● Melena (black, tarry stool) commonly used therapy for peptic ulcers is a
○ Upper GI alterations combination of antibioticsLinks to an external
● Hematochezia (bright fresh blood in stool) site., proton pump inhibitors, and bismuth salts
that suppress or eradicate the infection.
○ Lower GI alterations ○ PPI- Omeprazole
● Hematomesis (vomit with blood) ■ 3 times a day
○ Upper GI alterations ■ 14 days
● Coffee-ground emesis ■ 500 mg
○ Lower GI alterations ■ Watch out for constipation
● Dyspepsia/ Epigastric pain that may lead to risk for
● Nausea hemorrhoids.
● Belching ○ Bismuth eradicates infection
● Bloating ● Stress reduction and rest. Reducing
Complications: environmental stress requires physical and
➔ Perforation psychological modifications on the patient’s part
◆ An ulcer can go through all the layers as well as the aid and cooperation of family
of the digestive tract and form a hole members and significant others.
(perforation). This is called a perforated ● Smoking cessation. Studies have shown that
ulcer. A perforated ulcer lets food and smoking decreases the secretion of bicarbonate
digestive juices leak out of the digestive from the pancreas into the duodenum, resulting
tract. Leading to peritonitis and sepsis in increased acidity of the duodenum.
or septic shock ● Dietary modification. Avoiding extremes of the
◆ Administer Tranxemic acid to temperature of food and beverages and
decrease bleeding overstimulation from consumption of meat
◆ Clinical manifestations: extracts (more digestion, more secretion of HCl,
● Shoulder pain due to irritation more acid, more erosion), alcohol, coffee, and
of the phrenic nerve other caffeinated beverages, and diets rich in

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Cruz, Larraine Jhasmine D.
BSN-4E2

cream and milk should be implemented. ● Acute pain related to the effect of gastric acid
Surgical Management secretion on damaged tissue.
Surgical intervention is required to control bleeding in a ● Anxiety related to an acute illness.
few patients. The operative procedure of choice to control ● Imbalanced nutrition related to changes in the
bleeding from peptic ulcer disease is a vagotomy and diet.
pyloroplasty. During this procedure, the vagus nerve to ● Deficient knowledge about prevention of
the stomach is severed, eliminating the autonomic symptoms and management of the condition.
stimulus to the gastric cells and reducing hydrochloric Nursing Care Planning & Goals
acid production. Because the vagus nerve also stimulates ● Relief of pain.
motility, a pyloroplasty is performed to provide for ● Reduced anxiety.
gastric emptying. ● Maintenance of nutritional requirements.
● Pyloroplasty. Pyloroplasty involves transecting ● Knowledge about the management and
nerves that stimulate the acid secretion and prevention of ulcer recurrence.
opening the pylorus. ● Absence of complications.
Nursing Interventions
● Relieving Pain and Improving Nutrition
○ Administer prescribed medications.
○ Avoid aspirin, which is an
anticoagulant, and foods and beverages
that contain acid-enhancing caffeine
(colas, tea, coffee, chocolate), along
with decaffeinated coffee.
○ Practice SMALL FREQUENT
● Antrectomy. Antrectomy is the removal of the MEALS
pyloric portion of the stomach with anastomosis ○ Encourage the patient to eat regularly
to either the duodenum or jejunum. spaced meals in a relaxed atmosphere;
obtain regular weights and encourage
dietary modifications.
○ Encourage relaxation techniques.
● Reducing Anxiety
○ Assess what the patient wants to know
about the disease, and evaluate the level
of anxiety; encourage the patient to
express fears openly and without
criticism.
○ Explain diagnostic tests and
administering medications on schedule.
○ Interact in a relaxing manner, help in
identifying stressors, and explain
Nursing Management effective coping techniques and
All critically ill patients should be considered at risk relaxation methods.
for stress ulcers and GI hemorrhage. Routine ○ Encourage the family to participate in
assessment of gastric fluid pH monitoring is care, and give emotional support.
controversial.28 Maintaining the pH between 3.5 and 4.5 ● Monitoring and Managing Complications
is a goal of prophylactic therapy. Gastric pH If hemorrhage is a concern:
measurements made with litmus paper or direct ● Assess for faintness or dizziness and nausea,
nasogastric tube probes may be used to assess gastric before or with bleeding; test stool for occult or
fluid pH and the effectiveness of or need for prophylactic gross blood; monitor vital signs frequently
agents. Patients at risk also should be assessed for the (tachycardia, hypotension, and tachypnea).
presence of bright red or coffee ground emesis; bloody ● Insert an indwelling urinary catheter and
nasogastric aspirate; and bright red, black, or dark red monitor intake and output; insert and maintain
stools. Any signs of bleeding should be promptly reported an IV line for infusing fluid and blood.
to the physician. ○ IVF= PNSS, compatible with blood
Nursing Assessment for transfusion
● Assessment for a description of pain. ● Monitor laboratory values (hemoglobin and
● Assessment of relief measures to relieve the hematocrit).
pain. ● Insert and maintain a nasogastric tube and
● Assessment of the characteristics of the vomitus. monitor drainage; provide lavage as ordered.
● Assessment of the patient’s usual food intake ● Monitor oxygen saturation and administering
and food habits. oxygen therapy.
Nursing Diagnosis ● Place the patient in the recumbent position

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Cruz, Larraine Jhasmine D.
BSN-4E2

with the legs elevated to prevent hypotension, symptoms as well as substances that have
or place the patient on the left side to prevent acid-producing potential.
aspiration from vomiting. ● Lifestyle. It is important to counsel the patient to
● Treat hypovolemic shock as indicated. eat meals at regular times and in a relaxed
If perforation and penetration are concerns: setting and to avoid overeating.
● Note and report symptoms of penetration (back
and epigastric pain not relieved by medications
that were effective in the past). Liver Failure
● Note and report symptoms of perforation
(sudden abdominal pain, referred pain to Overview of the System
shoulders, vomiting and collapse, extremely
tender and rigid abdomen, hypotension and
tachycardia, or other signs of shock).
Home Management and Teaching Self-Care
● Assist the patient in understanding the condition
and factors that help or aggravate it.
● Teach patient about prescribed medications,
including name, dosage, frequency, and possible
side effects. Also, identify medications such as
aspirin that patients should avoid.
● Instruct patient about particular foods that will
upset the gastric mucosa, such as coffee, tea, Functions of the liver:
colas, and alcohol, which have acid-producing LIVER= THE RECYCLING ORGAN OF THE BODY
potential. 1. Detoxing ammonia
● Encourage the patient to eat regular meals in a
relaxed setting and to avoid overeating. Ammonia is the byproduct of protein, “PROTEIN
● Explain that smoking may interfere with ulcer TRASH”. The liver then converts ammonia into urea
healing; refer the patient to programs to assist (blood urea nitrogen/ BUN) which is secreted through
with smoking cessation. urine.
● Alert the patient to signs and symptoms of However, if cirrhosis or failure is present, levels of
complications to be reported. These ammonia increases leading to hepatic encephalopathy
complications include hemorrhage (cool skin, or the “cloudy toxic brain”
confusion, increased heart rate, labored Clinical manifestations:
breathing, and blood in the stool), penetration ● Decreased LOC
and perforation (severe abdominal pain, rigid ● Twitching of the extremities
and tender abdomen, vomiting, elevated ● Tremors
temperature, and increased heart rate), and ● Asterixis
pyloric obstruction (nausea, vomiting, distended Key assessment:
abdomen, and abdominal pain). To identify ● Hand movements
obstruction, insert and monitor nasogastric tube; ● Mental status
more than 400 mL residual suggests obstruction. ● Blood draws for ammonia levels
Evaluation 2. Drug metabolism
● Expected patient outcomes include: a. Leads to drug toxicity if not transported
○ Relief of pain.
due to liver alterations
○ Reduced anxiety.
○ Maintained nutritional requirements. b. Avoid acetaminophen to avoid further
○ Knowledge about the management and liver damage
prevention of ulcer recurrence. i. Antidote: acytcysteine
○ Absence of complications. 3. Storing glycogen
Discharge and Home Care Guidelines a. Hypoglycemia if there’s cirrhosis or liver
● Factors that affect. The nurse instructs the failure
patient about factors that relieve and those that
4. Producing the ABC
aggravate the condition.
● Medications. The nurse reviews information a. Albumin
about medications to be taken at home, b. Bile
including name, dosage, frequency, and possible c. Coagulants
side effects, stressing the importance of
continuing to take medications even after signs Albumin
and symptoms have decreased or subsided. ● Protein in the blood
● Diet. The nurse instructs the patient to avoid ● Responsible for:
certain medications and foods that exacerbate ○ Transportation of drug

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Cruz, Larraine Jhasmine D.
BSN-4E2

○ Attraction of water The clinical manifestation of sudden and severe hepatic

○ Binds with calcium for bone strength injury with the onset of coma and coagulopathy up to
If cirrhosis or failure is present: within 6 months. However, onset is usually Within 1-6
● The body can’t produce albumin causing weeks from the onset of any signs of illness.
○ Hypoalbumia
○ Drugs won’t transport= hepatotoxic
○ Osteoporosis due to lack of calcium
○ Water build up (mostly plasma)
■ Edema
■ 3rd spacing
● Ascutes
● Abdominal fluid
○ Hypocalcemia
■ TOP SIGNS AND
SYMPTOMS:
● Trousseu’s The causes of ALF include infections, medications,
● Chvostek’s toxins, hypoperfusion, metabolic disorders, and surgery,
however, viral hepatitis and medication-induced liver
damage are the predominant causes. Patients are usually
healthy before the onset of symptoms, because ALF tends
to occur in patients with no known liver history. A
thorough medication and health history is imperative to
determine a possible cause. The patient should be
questioned about exposure to environmental toxins,
hepatitis, intravenous drug use, sexual history, viral
hepatitis, medication toxicity, and poisoning. Additional
vascular causes such as thrombosis; ischemia;
Budd-Chiari syndrome (blocked venous outflow from
small hepatic veins to inferior vena cava from
Bile thrombosis); and metabolic disorders such as Reye
BILE= BILE BUS syndrome (acute, often fatal liver disease), Wilson disease
● Eliminates bilirubin and cholesterol out of the (disease of defective copper metabolism that damages
body liver and brain), galactosemia (rare disease in infants in
If cirrhosis or failure is present: which they cannot metabolize galactose, resulting in
● Increased bilirubin= jaundice hepatocellular damage), and fructose intolerance should
● Increased cholesterol= hyperlipidemia be considered.
● Acetaminophen-Related Liver:
○ The most common cause of ALF in the
Coagulant US.
The clotting factors responsible for clotting ○ Caused by overdose & toxicity.
If cirrhosis or failure is present, clotting decreases, risk ○ Acetaminophen-Alcohol poisoning.
for bleeding and hemorrhagic/hypovolemic shock ● Drug-induced injuries:
increases. ○ 10% of drug-induced liver injuries
progress to acute liver failure.
○ Anti-infectives, anticonvulsants, and
The most severe clinical consequences of liver disease is anti-inflammatory drugs most
hepatic failure. It generally develops as the end point of commonly implicated.
progressive damage to the liver. 80% to 90% of hepatic Pathophysiology
function must be lost before hepatic failure ensues. ALF is a result of massive necrosis of the hepatocytes. It
results in numerous derangements, including impaired
Acute Liver Failure bilirubin conjugation, decreased production of clotting
Acute liver failure (ALF) is a life-threatening condition factors, depressed glucose synthesis, and decreased
characterized by severe and sudden liver cell lactate clearance. This results in jaundice, coagulopathies,
dysfunction, coagulopathy, and hepatic encephalopathy. hypoglycemia, and metabolic acidosis. Other effects of
Although uncommon, ALF is associated with a mortality ALF include increased risk of infection and altered
rate of 40%, and it usually occurs in patients without carbohydrate, protein, and glucose metabolism.
preexisting liver disease. Because liver transplantation is Hypoalbuminemia, fluid and electrolyte imbalances, and
one of the few definitive treatments, a patient with ALF acute portal hypertension contribute to the development
should be transferred to a critical care unit and strongly of ascites. Hepatic encephalopathy is believed to result
considered for referral to a major medical center where from failure of the liver to detoxify various substances in
transplantation services are available. the bloodstream, and it may be worsened by metabolic

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Cruz, Larraine Jhasmine D.
BSN-4E2

and electrolyte imbalances. assessed by using a grading system that stages the
The patient may experience various other complications, encephalopathy according to the patient’s clinical
including cerebral edema, cardiac dysrhythmias, acute manifestations.
lung failure, sepsis, and AKI. Cerebral edema and
increased intracranial pressure (ICP) develop as a result
of breakdown of the bloodbrain barrier and astrocyte
swelling. Circulatory failure that mimics sepsis is
common in ALF and may exacerbate low cerebral
perfusion pressure. Hypoxemia, acidosis, electrolyte
imbalances, and cerebral edema can precipitate the
development of cardiac dysrhythmias. Acute lung failure
progressing to ARDS, intrapulmonary shunting,
ventilation-perfusion mismatch, sepsis, and aspiration
may contribute to the universal arterial hypoxemia.
Diagnostic findings include prolonged prothrombin
Clinical Manifestations
times; elevated levels of serum bilirubin, aspartate
● Yellowing of your skin and eyeballs (jaundice)
aminotransferase, alkaline phosphatase, and serum
ammonia; and decreased levels of serum albumin.
Arterial blood gases reveal respiratory alkalosis,
metabolic acidosis, or both. Hypoglycemia,
hypokalemia, and hyponatremia also may be
present.52,53 Factors I (fibrinogen), II (prothrombin), V,
VII, IX, and X are produced exclusively by the liver.
Prothrombin time may be the most useful of these in the
evaluation of acute ALF, because levels may be 40 to 80
seconds above control values. Test results show decreased
● Pain in your upper right abdomen levels of plasmin and plasminogen and increased levels
● Abdominal swelling of fibrin and fibrin-split products. Platelet counts may be
● Nausea less than 100,000/mm
● Vomiting Medical Management
● A general sense of feeling unwell (malaise) ● Paracetamol
● Disorientation or confusion ○ N-Acetylcysteine (antidote for
● Sleepiness acetaminophen)
● Encephalopathy ● HAV, HBV declining in importance
○ Increased ammonia in blood= ○ Lamivudine
neurological alterations ● HEV now a common cause HSV and other
○ LOC is the earliest sign Herpes group viruses
● Change in liver span (hepatomegaly) ○ Aciclovir, Ganciclovir
● Cerebral edema ● Allopathic (western and modern medicine)
● Hyperdynamic circulation and non-allopathic (non-conventional
● Right upper quadrant tenderness medicine)
● Ascites ○ Withdrawal
● Alcoholic hepatitis
○ Steroids, Pentoxifylline
● Autoimmune hepatitis
○ Corticosteroids
● Wilson’s disease
(rapid degeneration of
the liver; hallmark
sign: Kayser Fleischer
rings in the eyes)
○ Chelation
therapy
● Ischaemic hepatitis
○ Restoration of hepatic circulation
related to liver dialysis
The patient should be evaluated for the presence of ● Budd-Chiari syndrome due to thrombus or
asterixis, or “liver flap,” which is best described as the neoplasm
inability to voluntarily sustain a fixed position of the ○ Hepatic decompression
extremities. Asterixis is best recognized by downward
flapping of the hands when the patient extends the arms
and dorsiflexes the wrists. Hepatic encephalopathy is

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Cruz, Larraine Jhasmine D.
BSN-4E2

Bleeding may be difficult to control.

● Infections
○ People with acute liver failure are at an
increased risk of developing a variety
of infections, particularly in the blood
and in the respiratory and urinary tracts.
○ Treated with antibacterial and/or
antifungal drugs; treatment is started
as soon as patients show any sign of
infection
● Kidney failure
○ Kidney failure often occurs following
liver failure, especially in cases of
acetaminophen overdose, which
damages both your liver and your
● GPH, Acute fatty liver kidneys.
○ Delivery ○ Volume control of acetaminophen
Complications and management ○ Early use of renal replacement
● Encephalopathy therapy
○ Ornithine aspartate may aid ● Coma – Mental confusion
conversion of ammonia into glutamine ○ Difficulty concentrating and
in muscle disorientation (hepatic encephalopathy)
○ Neomycin may decrease can progress to coma if liver function
ammonia-producing bacterias does not return.
○ Lactulose Prevention
■ Laxative The best way to prevent liver failure is to limit your risk
■ Humans lose ammonia via of developing cirrhosis or hepatitis
fecal elimination or loose This can be done by following :
vowels 1. Dosage directions on all prescription, herbal and
● Expect diarrhea over-the-counter medications (including
■ Hypokalemia is normal and acetaminophen)
must be aided 2. Avoiding risky behavior
■ Avoid valsalva manuever= 3. Exercising caution when using any type of
increased risk for chemicals and living a healthy lifestyle.
hemorrhoids 4. Follow instructions on medications : the patient
■ Mnemonic: L-A-C must take the recommended dosage, and don't
● Laxative take more than that.
● Ammonia is 5. Alcohol amount if necessary must be limited, no
decreased more than one drink a day for women of all ages
● Cognitin returns and men older than 65 and no more than two
● Cerebral edema drinks a day for younger men.
○ Excessive fluid causes pressure to build 6. Avoid smoking
in your brain, which can displace brain 7. Vaccination against HBV
tissue outside of the space it normally 8. Avoid contact with other people's blood and
occupies (herniation). Cerebral edema body fluids.
can also deprive your brain of oxygen. 9. Don't eat wild mushrooms
○ Brief hyperventilation can be used, 10. Take care with aerosol sprays, insecticides,
particularly when herniation is fungicides, paint and other toxic chemicals
suspected. 11. Healthy weight as
○ Head-up position a. Obesity can cause a condition called
○ Early intubation nonalcoholic fatty liver disease, which
● Coagulopathy may include fatty liver, hepatitis and
○ Platelet transfusions cirrhosis.
○ H2blockers may help prevent GI
bleeding
● Bleeding disorders Chronic Liver Failure
○ A failing liver isn't able to produce Inability of the liver (for 6 months and beyond) to
sufficient amounts of clotting factors, perform its normal synthetic and metabolic function as
which help blood to clot. People with part of normal physiology. Chronic liver failure is a
acute liver failure often develop deterioration of liver function that occurs over a long
bleeding from the gastrointestinal tract. period of time, generally months to years It usually

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Cruz, Larraine Jhasmine D.
BSN-4E2

occurs in the context of cirrhosis. ● Ascites

Chronic liver failure is the most common form of liver ● Hepatic encephalopathy
failure ● Skin
Common Causess: ○ Palmar erythema
● Chronic hepatitis ○ Spider angioma
● Liver cirrhosis ○ Caput medusa
○ Development of scar tissue that ○ Pigmentations
replaces normal parenchyma. This scar ○ Pruritus
tissue blocks the portal flow of blood ● Hematological and Endocrine
through the organ therefore disturbing ○ Anemia
normal function. Damage to the hepatic ○ Bleeding tendency
parenchyma leads to activation of the ○ Gynecomatia
stellate cell, which increases fibrosis ○ Feminine
and obstructs blood flow in the distribution of
circulation. It secretes TGF-β1, which hair
leads to a fibrotic response and ● Sign associated with
proliferation of connective tissue. etiology
Furthermore, it secretes TIMP 1 and 2, ○ Parotidomegally
naturally occurring inhibitors of matrix ○ Dupuytren’s
metalloproteinases, which prevents contracture
them from breaking down fibrotic (Viking disease)
material in the extracellular matrix
● Acetaminophen, NSAIDs, antibiotics
○ Hepatotoxic drugs
● Herbal medical ■ Thickened hand fascia
● Fatty liver
● Vascular diseases
● Excessive alcohol intake
○ Chronic consumption of alcohol results
in the secretion of proinflammatory
cytokines (TNF-alpha, Interleukin 6
and Interleukin 8). These factors cause
inflammation, apoptosis and eventually
fibrosis of liver cells.
● Hemochromatosis
○ Disorder related to deficiency of the
iron regulatory hormone hepcidin.
HHC is an autosomal recessive genetic
disease in which increased intestinal
absorption of iron causes accumulation
in tissues, especially the liver, which ○ Peripheral neuropathy
may lead to organ damage. ○ Signs of right heart failure
● Autoimmune hepatitis ○ Kayser-Fleisher rings
○ Anomalous presentation of human ● Other:
leukocyte antigen (HLA) class II on the ○ Leukonychia (White nails)
surface of hepatocytes causes a ○ Hepato-renal syndrome
cell-mediated ○ Hepato-pulmonary syndrome
immune ○ Increase incidence of infection
response against ● Serious symptoms:
the liver ○ Jaundice
Clinical Manifestations: ○ Fasting hypoglycemia
● Initial symptoms: ○ Hypoestregonemia
○ Fatigue, ○ Ascites
drowsiness ○ Bleeding form esophageal varices
○ Dirrhrea ○ Fever and septicemia
○ Weight loss Laboratory Investigations
and loss in ● CBC with platelets.
appetite ● Prothrombin time.
○ Nausea ● Serum bilirubin.
● Fever & septicemia ● Serum albumin.
● Jaundice ● ALT – AST

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Cruz, Larraine Jhasmine D.
BSN-4E2

● ALP Management of Ascites

Radiological Investigations ● PARACENTESIS
● Ultrasound ● Empty bladder
● MRI ● NPO for 8 hours
● Ultrasonography (US) ● Limit oral fluid intake (1-2 glasses/day)
● EEG ● Monitor VS especially BP
● MR spectroscopy (MRS) ● Abdominal circumference and weight
● CSF ● Head of the bead up
Medical Management ● Respiratory status is back to normal
● The only curative treatment is liver
Nursing Management
transplantation
● ICU to maintain BP, pulse, mental status with Nursing Assessment
nasogastric tube ● Past health history
● Glucose to treat hypoglycemia ● Medications
● Antibiotics ● Chronic alcoholism
Complications ● Weight loss
Chronic injury to the liver, regardless of the cause, results Nursing Diagnoses
in a wounding response that leads to fibrosis, and
ultimately scarring and replacement of normal liver ● Imbalanced nutrition: less than body requirements
architecture by regenerative nodules. ● Impaired skin integrity
● Portal hypertension ● Ineffective breathing pattern
○ Ascites an accumulation of fluid in the ● Risk for injury
peritoneal cavity. Planning
○ Hypersplenism reduction in the number ● Overall goals:
of circulating blood cells affecting
● Relief of discomfort
granulocytes, erythrocytes or platelets.
○ Lower esophageal varices and rectal ● Minimal to no complications
varices ● Return to as normal a lifestyle as possible
● Synthetic Dysfunction Nursing Implementation
○ Hypoalbuminemia. ● Health Promotion
○ Coagulopathy. in which the blood’s ○ Treat alcoholism
ability to clot (coagulate) is impaired. ○ Identify hepatitis early and treat
● Hepatopulmonary Syndrome a syndrome of
○ Identify biliary disease early and treat
shortness of breath and hypoxemia caused by
vasodilation in the lungs of patients with liver ● Acute Intervention
disease. ○ Rest
● Hepatorenal Syndrome a life-threatening ○ Edema and ascites
medical condition that consists of rapid ○ Paracentesis
deterioration in kidney function. ○ Skin care
● Encephalopathy a spectrum of reversible
○ Dyspnea
neuropsychiatric abnormalities.
● Hepatocellular Carcinoma ○ Nutrition
Prevention ● Ambulatory and Home Care
1. Get vaccinated against hepatitis A and B. ○ Symptoms of complications
2. Do not use multiple medications or illicit drugs ○ When to seek medical attention
unwisely. ○ Remission maintenance
3. If you have any member of the family of friend ○ Abstinence from alcohol
who is sick, avoid contact with blood or bodily
Evaluation
fluids.
4. Eat healthy exercise and keep your weight ● Maintenance of normal body weight
down. ● Maintenance of skin integrity
5. Do not drink alcohol. ● Effective breathing pattern
6. Screening for Hepatocellular Cancer. ● No injury
● No signs of infection

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Cruz, Larraine Jhasmine D.
BSN-4E2

Renal Alterations
Overview of the System are retroperitoneal. Each kidney is held in place by
The principal function of the urinary system is to maintain connective tissue, called renal fascia, and is surrounded
the volume and composition of body fluids within normal by a thick layer of adipose tissue, called perirenal fat,
limits. One aspect of this function is to rid the body of waste which helps to protect it. A tough, fibrous, connective
tissue renal capsule closely envelopes each kidney and
products that accumulate as a result of cellular metabolism,
provides support for the soft tissue that is inside.
and, because of this, it is sometimes referred to as the
excretory system. In the adult, each kidney is approximately 3 cm thick, 6
Although the urinary system has a major role in excretion, cm wide, and 12 cm long. It is roughly bean-shaped with
other organs contribute to the excretory function. The lungs an indentation, called the hilum, on the medial side. The
in the respiratory system excrete some waste products, such hilum leads to a large cavity, called the renal sinus, within
the kidney. The ureter and renal vein leave the kidney,
as carbon dioxideand water. The skin is another excretory
and the renal artery enters the kidney at the hilum.
organ that rids the body of wastes through the sweat glands.
The liver and intestines excrete bile pigments that result
from the destruction of hemoglobin. The major task of
excretion still belongs to the urinary system. If it fails the
other organs cannot take over and compensate adequately.
The urinary system maintains an appropriate fluid volume
by regulating the amount of water that is excreted in the
urine. Other aspects of its function include regulating the
concentrations of various electrolytes in the body fluids and
maintaining normal pH of the blood.
In addition to maintaining fluid homeostasis in the body, the
urinary system controls red blood cellproduction by
The outer, reddish region, next to the capsule, is the renal
secreting the hormone erythropoietin. The urinary system
cortex. This surrounds a darker reddish-brown region
also plays a role in maintaining normal blood pressure by called the renal medulla. The renal medulla consists of a
secreting the enzyme renin. series of renal pyramids, which appear striated because
The urinary system consists of the kidneys, ureters, urinary they contain straight tubular structures and blood vessels.
bladder, and urethra. The kidneys form the urine and The wide bases of the pyramids are adjacent to the cortex
account for the other functions attributed to the urinary and the pointed ends, called renal papillae, are directed
toward the center of the kidney. Portions of the renal
system. The ureters carry the urine away from kidneys to the
cortex extend into the spaces between adjacent pyramids
urinary bladder, which is a temporary reservoir for the urine. to form renal columns. The cortex and medulla make up
The urethra is a tubular structure that carries the urine from the parenchyma, or functional tissue, of the kidney.
the urinary bladder to the outside. The central region of the kidney contains the renal pelvis,
1. Kidneys which is located in the renal sinus, and is continuous with
2. Ureters the ureter. The renal pelvis is a large cavity that collects
3. Urinary Bladder the urine as it is produced. The periphery of the renal
pelvis is interrupted by cuplike projections called calyces.
4. Urethra
A minor calyxsurrounds the renal papillae of each
Kidneys pyramid and collects urine from that pyramid. Several
The kidneys are the primary organs of the urinary system. minor calyces converge to form a major calyx. From the
The kidneys are the organs that filter the blood, remove major calyces, the urine flows into the renal pelvis; and
the wastes, and excrete the wastes in the urine. They are from there, it flows into the ureter.
the organs that perform the functions of the urinary Each kidney contains over a million functional units,
system. The other components are accessory structures to called nephrons, in the parenchyma (cortex and medulla).
eliminate the urine from the body. A nephron has two parts: a renal corpuscle and a renal
The paired kidneys are located between the twelfth tubule.The renal corpuscle consists of a cluster of
thoracic and third lumbar vertebrae, one on each side of capillaries, called the glomerulus, surrounded by a
the vertebral column. The right kidney usually is slightly double-layered epithelial cup, called the glomerular
lower than the left because the liver displaces it capsule. An afferent arteriole leads into the renal
downward. The kidneys, protected by the lower ribs, lie corpuscle and an efferent arteriole leaves the renal
in shallow depressions against the posterior abdominal corpuscle. Urine passes from the nephrons into collecting
wall and behind the parietal peritoneum. This means they ducts then into the minor calyces.

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Cruz, Larraine Jhasmine D.
BSN-4E2

The juxtaglomerular apparatus, which monitors blood in the diet, fluid volume, and excretion from the kidneys.
pressure and secretes renin, is formed from modified cells The body forms approximately 25 to 28 g of urea per day.
in the afferent arteriole and the ascending limb of the More urea is formed if protein intake is high or if the
nephron loop.
individual is in a catabolic state and is breaking down
body protein stores. Urea is primarily excreted in the
urine and accumulates if the glomerulus is unable to filter
it from the blood. Creatinine
Creatinine is an end product of protein metabolism
produced by the muscles. Creatinine is normally
completely filtered and minimally reabsorbed by the
kidneys. As a result, creatinine is excreted in the urine.
Similar to urea, creatinine accumulates when the
glomerulus is unable to filter it from the blood. The level
of creatinine in the blood provides an indicator of kidney
function and is used to estimate the eGFR.
Blood Pressure Regulation
The kidneys regulate arterial blood pressure by
maintaining the circulating blood volume by means of
fluid balance and by altering peripheral vascular
resistance through the renin angiotensin aldosterone
system (RAAS). Regulation by the RAAS occurs in the
juxtaglomerular apparatus (JGA), a group of specialized
cells located around the afferent arteriole where the distal
tubule and afferent arteriole make contact. Another group
of specialized cells is located near the distal tubule;
known as the macula densa, these cells control a feedback
mechanism from the distal tubule to the afferent arteriole
to control blood flow through the afferent arteriole

The formation of urine through the processes previously

described is a major function of the kidneys. The kidneys
are also responsible for other functions essential to
maintaining homeostasis, including the elimination of
metabolic wastes, blood pressure regulation, the
regulation of erythrocyte production, the activation of
vitamin D, prostaglandin synthesis, acid base balance,
and fluid electrolyte balance.
Elimination of Metabolic Wastes
Metabolic processes in the body produce waste products
that are selectively filtered out of the circulation by the
kidneys. Urea, uric acid, and creatinine are byproducts of
protein metabolism that the kidneys filter out of the
circulation and excrete in the urine. Metabolic acids,
bilirubin, and medication metabolites are also eliminated
as waste products.
Urea
Urea and creatinine are the primary waste products that
are measured in determining kidney function. Urea is
measured as blood urea nitrogen; this is the end product
of protein metabolism and results from the breakdown of
ammonia in the liver. The level of urea in the blood is
influenced by protein breakdown, the amount of protein

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Cruz, Larraine Jhasmine D.
BSN-4E2

Erythrocyte Production Fluid Balance

The kidneys secrete erythropoietin, the hormone that Regulation of the total amount of water in the body is
controls erythrocyte (red blood cell) production in the vital for homeostasis, and it is one of the most important
bone marrow. Erythropoietin is released in response to a functions of the kidneys. In the absence of effective
decrease in the amount of oxygen delivered to the kidney function, fluid volume overload occurs and
kidneys, such as in anemia or prolonged hypoxia. The threatens homeostasis. Similarly, if the kidneys are unable
hormone remains active for approximately 24 hours after to preserve adequate amounts of fluid, a severe volume
release and stimulates the bone marrow to increase the deficit occurs that also disrupts homeostasis.
production of erythrocytes. The absence of The fluid of the body is present in distinct internal spaces
erythropoietin, which occurs in individuals with kidney or compartments. The compartments are separated from
failure, results in a profound anemia that is treated by each other by semipermeable membranes with openings
administering synthetic erythropoietin or by blood (pores) that allow molecules of specific size and
transfusion therapy molecular weight to pass through while preventing larger,
Vitamin D Activation heavier molecules from doing so. As a result of the
The kidneys convert vitamin D from food sources into an semipermeable membrane, fluid movement between the
active form for use by the body. Active vitamin D compartments is dynamic and constant. Water makes up
stimulates the absorption of calcium by the intestine and 45% to 60% of body weight. The body has two main
reabsorption of calcium by the tubules so that calcium is fluid compartments: intracellular and extracellular. The
available for bone and tooth metabolism and blood intracellular compartment is the fluid inside each of the
clotting functions. When the kidneys fail, the body is body’s cells and accounts for 40% of the total body water
unable to convert dietary vitamin D to its active form, content. The remaining fluid is outside the body’s cells
calcium is poorly absorbed, and bone disease and other and makes up the extracellular compartment. The
immunologic deficiencies result. Lack of vitamin D may extracellular compartment is composed of two distinct
also be responsible for changes in the immune system subcompartments: intravascular and interstitial. The
that increase the risk of infection in patients with chronic intravascular compartment, referring to the fluid within
kidney disease. the blood vessels, accounts for 5% of the body water. The
Prostaglandin Synthesis interstitial compartment corresponds to the fluid in the
Prostaglandins are vasoactive substances that dilate or tissue spaces outside of the body cells and the blood
constrict the arteries. The kidney produces several vessels and accounts for 15% of body water. With an
prostaglandins; two have vasodilatory effects: increase in body fat, the body fluid percentage decreases
prostaglandin E1 (PGE1) and prostaglandin I2 (PGI2). because fat contains a smaller and less significant amount
The prostaglandins produced by the kidneys have only of water than muscle.
local blood flow effects with minimal or no systemic
effects. The primary prostaglandins produced by the
kidneys are the vasodilators PGE1 and PGI2, which act
on the afferent arteriole to maintain blood flow and
glomerular perfusion and filtration. The vasodilating
effects of the prostaglandins also counteract the effects of
angiotensin II and the sympathetic nervous system on the
kidneys and maintain blood flow to the kidney despite
systemic vasoconstriction.
Acid Base Balance
The kidneys are actively involved in acid base regulation
by reabsorbing or excreting acids and bases in the kidney Electrolytes are elements or compounds that, when
tubules. Bicarbonate, the principal blood buffer, is dissolved in water, dissociate into ions, electrically
reabsorbed from the tubules, and hydrogen, a potent charged atomic particles. Ions in solution in the fluid
organic acid, is secreted into the tubules. However, the allow the fluid to conduct an electrical current. A balance
tubules do not function as rapidly in altering acid base exists between cations (positively charged ions), anions
concentrations as do the lungs; the kidneys regulate the (negatively charged ions), and other substances in the
day-to-day balance rather than coping with emergencies fluid compartments. Maintaining this balance is important
requiring an immediate physiologic response. to the normal function of all body systems. Electrolytes
exist in differing amounts in each of the fluid
compartments

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mucosa has numerous folds called rugae. The rugae and

transitional epithelium allow the bladder to expand as it
fills.
The second layer in the walls is the submucosa, which
supports the mucous membrane. It is composed of
connective tissue with elastic fibers.
The next layer is the muscularis, which is composed of
smooth muscle. The smooth muscle fibers are interwoven
in all directions and, collectively, these are called the
detrusor muscle. Contraction of this muscle expels urine
from the bladder. On the superior surface, the outer layer
of the bladder wall is parietal peritoneum. In all other
regions, the outer layer is fibrous connective tissue.

There is a triangular area, called the trigone, formed by

three openings in the floor of the urinary bladder. Two of
the openings are from the ureters and form the base of the
trigone. Small flaps of mucosa cover these openings and
act as valves that allow urine to enter the bladder but
prevent it from backing up from the bladder into the
ureters. The third opening, at the apex of the trigone, is
Ureters the opening into the urethra. A band of the detrusor
Each ureter is a small tube, about 25 cm long, that carries muscle encircles this opening to form the internal urethral
urine from the renal pelvis to the urinary bladder. It sphincter.
descends from the renal pelvis, along the posterior
abdominal wall, which is behind the parietal peritoneum,
and enters the urinary bladder on the posterior inferior Urethra
surface. The final passageway for the flow of urine is the urethra,
The wall of the ureter consists of three layers. The outer a thin-walled tube that conveys urine from the floor of the
layer, the fibrous coat, is a supporting layer of fibrous urinary bladder to the outside. The opening to the outside
connective tissue. The middle layer, the muscular coat, is the external urethral orifice. The mucosal lining of the
consists of the inner circular and outer longitudinal urethra is transitional epithelium. The wall also contains
smooth muscle. The main function of this layer is smooth muscle fibers and is supported by connective
peristalsis: to propel the urine. The inner layer, the tissue.
mucosa, is transitional epithelium that is continuous with The internal urethral sphincter surrounds the beginning of
the lining of the renal pelvis and the urinary bladder. This the urethra, where it leaves the urinary bladder. This
layer secretes mucus, which coats and protects the surface sphincter is smooth (involuntary) muscle. Another
of the cells. sphincter, the external urethral sphincter, is skeletal
(voluntary) muscle and encircles the urethra where it goes
through the pelvic floor. These two sphincters control the
Urinary Bladder flow of urine through the urethra.
The urinary bladder is a temporary storage reservoir for In females, the urethra is short, only 3 to 4 cm (about 1.5
urine. It is located in the pelvic cavity, posterior to the inches) long. The external urethral orifice opens to the
symphysis pubis, and below the parietal peritoneum. The outside just anterior to the opening for the vagina.
size and shape of the urinary bladder varies with the In males, the urethra is much longer, about 20 cm (7 to 8
amount of urine it contains and with the pressure it inches) in length, and transports both urine and semen.
receives from surrounding organs. The first part, next to the urinary bladder, passes through
The inner lining of the urinary bladder is a mucous the prostate gland and is called the prostatic urethra. The
membrane of transitional epithelium that is continuous second part, a short region that penetrates the pelvic floor
with that in the ureters. When the bladder is empty, the and enters the penis, is called the membranous urethra.

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The third part, the spongy urethra, is the longest region.

This portion of the urethra extends the entire length of the
penis, and the external urethral orifice opens to the
outside at the tip of the penis.

Acute Renal Failure

The most common renal problem seen in critically ill
patients is the development of acute kidney injury (AKI),
previously termed as acute renal failure (ARF).
Acute kidney injury (AKI) describes the spectrum of acute
onset kidney disorders that can range from mild impairment
of kidney function through acute kidney failure that requires
For the purpose of determining an appropriate plan of care,
renal replacement therapy (dialysis). AKI is characterized by
AKI is often categorized into prerenal, intrarenal, or
a sudden increase in creatinine and an abrupt decline in
postrenal causes. Each category of AKI has different
urine output signaling a decrease in glomerular filtration
etiologies, pathophysiology, laboratory findings, and clinical
rate (GFR) and retention of products in the blood that are
presentation. However, the common pathologic pathway for
normally excreted by the kidneys. AKI disrupts electrolyte
decreased glomerular filtration rate (GFR) is the reduction in
balance, acid base homeostasis, and fluid volume
renal blood flow. In the critical care unit, the majority of the
equilibrium. A transition to use of the word kidney rather
cases of AKI are caused by the combination of impaired
than renal reflects a trend in the nephrology literature that
renal perfusion, sepsis, and nephrotoxic agents.
emphasizes the vulnerability of the kidney during critical
illness.
Oliguria, urine output of less than 400 mL/day, is a common
finding in AKI. The development of AKI in acutely ill
patients has an estimated mortality of 40% to 50%, and
higher among intensive care unit (ICU) patients(> 50% in
most of the studies). Patients who develop AKI due to sepsis
have higher mortality. A history of chronic kidney disease
(CKD) complicates the clinical course of any critical illness.
The RIFLE criteria and Acute Kidney Injury Network
(AKIN) criteria are the most commonly used classification
systems for AKI (Table below) RIFLE is an acronym for:
Risk of renal dysfunction, Injury to the kidney, Failure of
kidney function, Loss of kidney function, and End-stage Prerenal / Acute Kidney lnjury
Physiologic conditions that lead to decreased perfusion
kidney disease.
of the kidneys, without intrinsic damage to the renal
tubules, are identified as prerenal AKI (See Figure 1).
The decrease in renal arterial perfusion causes a decrease
in the rate of filtration of blood through the glomerulus.
When perfusion pressure falls to less than 80 mm Hg,
protective autoregulation is lost, further decreasing
glomerular filtration. Renal tubular function, at this point,
is still completely normal. As a result of the decreased
GFR, the kidneys are unable to adequately filter waste
products from the blood. Consequently, more Na+ and
water are reabsorbed by the kidneys, resulting in oliguria.
If the decreased perfusion state persists, irreversible
damage to the renal tubules may occur, resulting in
intrarenal AKI. Most forms of prerenal AKI are easily
reversed by treating the cause and increasing renal
perfusion.
Intrarenal / Acude Kidney Injury
Physiologic conditions that cause damage to the renal
tubule, glomerulus, or renal blood vessels are
identified as intrarenal AKI. Following prolonged
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Cruz, Larraine Jhasmine D.
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mechanical ventilatory support are rarely sufficient to
decreases in renal perfusion, the kidneys gradually suffer
damage that is not readily reversed with the restoration of reverse the metabolic acidosis. Acidosis in AKI is complex,
renal perfusion. Acute tubular necrosis is the most as evidenced by the fact that many patients with AKI
common cause of AKI. maintain a normal anion gap; the reasons for this are
When the insult to the kidney is nephrotoxins unknown.
(medications or other substances that cause direct damage The BUN level is an unreliable indicator of kidney injury
to the kidney), the nephron damage occurs primarily at as an individual test. The BUN concentration is changed by
the tubular epithelial layer. Because this layer has the
protein intake, blood in the gastrointestinal tract, and cell
ability to regenerate, rapid healing often occurs following
nephrotoxic insults. When the insult is ischemic or catabolism, and it is diluted by fluid administration. A
inflammatory, the nephron's basement membrane is also BUN-to-creatinine ratio may be calculated to determine the
damaged and regeneration is not possible. Ischemic and cause of AKI. The BUN-to-creatinine ratio is most useful in
inflammatory insults are more likely to cause CKD than diagnosing prerenal AKI (often described as prerenal
nephrotoxic insults. azotemia), in which the BUN level is greatly elevated
The underlying pathophysiologic abnormality in relative to the serum creatinine value, although critically ill
intrarenal AKI is renal cellular damage. In healthy
kidneys, the glomerulus acts as a filter, preventing the patients can be developing AKI before changes in this ratio
passage of large molecules into the glomerular filtrate. are evident. The term azotemia is used to describe an acute
Damage to the glomerulus allows protein and cellular increase in the BUN level often associated with prerenal
debris to enter the renal tubules, leading to intraluminal AKI. Uremia is another term used to describe an
obstruction. elevated BUN value.
Contrast-induced nephropathy (CIN) is seen in about Creatinine is a by-product of muscle metabolism that is
10% of patients with risk factors receiving contrast
formed nonenzymatically from creatine in muscles.
media. The risk factors include diabetes, advanced age,
CKD, and hypovolemia. Contrast characteristics ( Creatinine is completely excreted when kidney function is
osmolality, iconicity, and molecular structure), and high normal. Consequently, when the kidneys are not working,
or repetitive doses of intravenous (IV) contrast also the serum creatinine level rises. Even small increases in
impact the risk. CIN is defined as a 25% increase in serum creatinine will represent a significant decline in GFR.
creatinine or an absolute increase of 0.5 mg/dL from Serum creatinine level is assessed daily to follow the trend
baseline within 48 to 72 hours of intravenous contrast of kidney function and to determine whether it is stable,
administration. The condition resolves in 7 to 10 days.
improving, or worsening.
The patient may be oliguric or may have no decrease in
urine output. The pathophysiological changes of CIN are If the patient is making sufficient urine, urinary creatinine
medullary hypoxia that is caused by an initial clearance can be measured. A normal urinary creatinine
vasodilation followed by a prolonged renal clearance rate is 120 mL/min, but this value decreases with
vasoconstriction and direct epithelial cell toxicity. kidney failure. Critical care patients with severe AKI
Postrenal / Acute Kidney Injury manifest elevated serum creatinine and may be oliguric.
Physiologic conditions that partially or completely Consequently, the urinary creatinine clearance rate is rarely
obstruct urine flow from the kidney to the urethral meatus
can cause postrenal AKI (see Figure 1 ). Partial measured during critical illness.
obstruction increases renal interstitial pressure, which in The fractional excretion of sodium (FENa) in the urine
turn increases Bowman capsule pressure and opposes can be measured early in the course of AKI to
glomerular filtration. Complete obstruction leads to urine differentiate between prerenal AKI and interrenal AKI
backup into the kidney, eventually compressing the (parenchymal). An FENa value less than 1% (in the
kidney. With complete obstruction, there is no urine absence of diuretics) suggests prerenal compromise, because
output from the affected kidney. Postrenal failure is an
resorption of almost all of the filtered sodium is an
uncommon cause of AKI in critically ill patients. The
treatment for postrenal failure is focused on removing the appropriate response to decreased perfusion to the kidneys.
obstruction. If diuretics are administered, the test is not helpful. An
FENa value greater than 2% implies that the kidney cannot
Laboratory and diagnostics
concentrate the sodium and that the damage is intrarenal
Acidosis (pH less than 7.35) is one of the trademarks of a
(AKI). FENa values do not have any predictive benefit in
severe acute kidney insult. Metabolic acidosis occurs as a
critical illness and are rarely measured. Urinary sodium is
result of the accumulation of waste products in the
measured in milliequivalents per liter. Interpretation of
bloodstream and tissues. The acid waste products consist of
results is similar to the FENa. A urinary sodium
strong negative ions (anions), elevated serum phosphorus
concentration less than 10 mEq/L (low) suggests a prerenal
levels (hyperphosphatemia), and other normally unmeasured
condition. A urinary sodium level greater than 40 mEq/L (in
ions (e.g., sulfate, urate, lactate) that decrease the serum pH.
the presence of elevated serum creatinine and the absence of
A low serum albumin concentration, which often occurs in
a high sodium load) suggests that intrarenal damage has
AKI, has a slight alkalinizing effect, but it is not enough to
occurred. As with other urinalysis tests, the use of diuretics
offset the metabolic acidosis. Respiratory compensation and
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invalidates any results. Because diuretics alter resorption of especially early in disease. Indeed, the rise of serum
water and produce dilute urine, the test result does not creatinine may not be evident before 50% of the GFR is lost.
reflect actual kidney function. It cannot be overstated that the current treatment for AKI is
Clinical manifestations mainly supportive in nature; no therapeutic modalities to
date have shown efficacy in treating the condition.
Therapeutic agents (eg, dopamine, nesiritide, fenoldopam,
mannitol) are not indicated in the management of AKI and
may be harmful for the patient.
Maintenance of volume homeostasis and correction of
biochemical abnormalities remain the primary goals of
treatment and may include the following measures:
1. Correction of fluid overload with furosemide
2. Correction of severe acidosis with bicarbonate
administration, which can be important as a bridge
to dialysis
3. Correction of hyperkalemia
4. Correction of hematologic abnormalities (eg,
anemia, uremic platelet dysfunction) with measures
such as transfusions and administration of
desmopressin or estrogens

● Oliguric Phase
○ Urine output 0.5mL/kg/hr
○ Nausea and Vomiting
○ Irritability
○ Drowsiness, confusion, coma
○ Restlessness, twitching, seizure night
Nursing Management
restlessness of legs
Acute renal failure (ARF), also known as acute kidney
○ Increased serum potassium, BUN,
failure or acute kidney injury, is the abrupt loss of kidney
Creatinine
function. The glomerular filtration rate (GFR) falls over a
○ Increased calcium, Sodium, pH, and CO2
period of hours to a few days and is accompanied by
○ Anemia
concomitant rise in serum creatinine and urea nitrogen. If
○ Pulmonary Edema,
left untreated, acute renal failure may complicate to chronic
○ Hypertension
renal failure.
○ Albuminuria
Nursing goal of treating patients with acute renal failure is to
● Diuretic Phase or Recovery Phase
correct or eliminate any reversible causes of kidney failure.
○ Urinary output 4-5 L/d
Provide support by taking accurate measurements of intake
○ Increased serum
and output, including all body fluids, monitor vital signs and
○ Sodium and Potassium
maintain proper electrolyte balance.
○ Increased mental and physical activity
Here are six (6) nursing care plans (NCP) and nursing
Medical Management
diagnosis for patients with acute renal failure:
Measures to correct underlying causes of acute kidney injury
1. Excess Fluid Volume
(AKI) should begin at the earliest indication of renal
2. Risk for Decreased Cardiac Output
dysfunction. Serum creatinine does not rise to abnormal
3. Risk for Imbalanced Nutrition: Less Than Body
levels until a large proportion of the renal mass is damaged,
Requirements
because the relationship between the glomerular filtration
4. Risk for Infection
rate (GFR) and the serum creatinine level is not linear,
5. Risk for Deficient Fluid Volume
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6. Deficient Knowledge
occur because of: (1) failure of the
7. Other Possible Nursing Care Plans kidneys to excrete urine, (2) excess
Excess Fluid Volume fluid resuscitation during efforts to treat
May be relate to hypovolemia and/or hypotensionor
● Compromised regulatory mechanism (renal convert oliguric phase of renal failure,
failure) (3) changes in the renin-angiotensin
● Intake greater than output, oliguria; changes in system. Invasive monitoring may be
urine specific gravity needed for assessing intravascular
● Venous distension; blood pressure (BP)/central volume, especially in patients with poor
venous pressure (CVP) changes cardiac function.
● Generalized tissue edema, weight gain ● Auscultate lung and heart sounds.
● Changes in mental status, restlessness ○ Fluid overload may lead to pulmonary
● Decreased Hb/hematocrit (Hct), altered edema and HF evidenced by
electrolytes; pulmonary congestion on x-ray development of adventitious breath
Desired Outcomes sounds, extra heart sounds.
Display appropriate urinary output with specific ● Assess level of consciousness.
gravity/laboratory studies near normal; stable weight, ○ Investigate changes in mentation,
vital signs within patient’s normal range; and absence of presence of restlessness. May reflect
edema fluid shifts, accumulation of toxins,
Nursing Interventions acidosis, electrolyte imbalances, or
● Accurately record intake and output (I&O) developing hypoxia.
noting to include “hidden” fluids such as IV ● Scatter desired beverages throughout the
antibiotic additives, liquid medications, frozen 24-hour period and give various offering (hot,
treats, ice chips. Religiously measure cold, frozen).
gastrointestinal losses and estimate insensible ○ Helps avoid periods without fluids,
losses (sweating), including wound drainage, minimizes boredom of limited choices,
nasogastric outputs, and diarrhea. and reduces sense of deprivation and
○ Decrease in output (to less than 400 ml thirst.
per 24 hours) may indicate acute ● Correct any reversible cause of ARF: replace
failure, especially in high-risk patients. blood loss, maximize cardiac output, discontinue
Accurate monitoring of I&O is nephrotoxic drug, relieve obstruction via
necessary for determining renal surgery.
function and fluid replacement needs ○ Kidneys may be able to return to
and reducing risk of fluid overload. Do normal functioning, preventing or
note that hypervolemia usually occurs limiting residual effects.
in anuric phase of ARF and may mask ● Use appropriate safety measures (raising side
the symptoms. rails and restraints.
● Monitor urine specific gravity. ○ Patient with CNS involvement may be
○ Measures the kidney’s ability to dizzy and/or confused.
concentrate urine. In intrarenal failure, ● Monitor diagnostic studies:
specific gravity is usually equal to or ● Blood urea nitrogen (BUN), creatinine (cr)
less than 1.010, indicating loss of ○ BUN assess management of renal
ability to concentrate the urine. dysfunction. Both values may increase
● Weigh daily at same time of day, on same scale, but creatinine is a better indicator of
with same equipment and clothing. renal function because it is not affected
○ Daily body weight is best monitor of by hydration, diet, and tissue
fluid status. A weight gain of more than catabolism. Dialysis is usually
0.5 kg/day suggests fluid retention. indicated if ratio is higher than 10:1 or
● Assess skin, face, dependent areas for edema. if therapy fails to indicate fluid
○ Evaluate degree of edema (on scale of overload or metabolic acidosis.
+1–+4). Edema occurs primarily in ● Urine sodium and Cr.
dependent tissues of the body, (hands, ○ In ATN, tubular functional integrity is
feet, lumbosacral area). Patient can gain lost and sodium resorption is impaired,
up to 10 lb (4.5 kg) of fluid before resulting in increased sodium excretion.
pitting edema is detected. Periorbital Urine creatinine is usually decreased as
edema may be a presenting sign of this serum creatinine elevates.
fluid shift because these fragile tissues ● Serum sodium.
are easily distended by even minimal ○ Hyponatremia may result from fluid
fluid accumulation. overload (dilutional) or kidney’s
● Monitor heart rate (HR), BP, and JVD/CVP. inability to conserve sodium.
○ Tachycardia and hypertension can Hypernatremia indicates total body

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water deficit. GFR.

● Serum potassium. ○ Prostaglandins.
○ Lack of renal excretion and/or selective ■ Vasodilatory effect may
retention of potassium to excrete excess improve circulating volume
hydrogen ions leads to hyperkalemia, and reestablish renal blood
requiring prompt intervention. flow to aid in clearing
● Hb/Hct. nephrotoxic agents from
○ Decreased values may indicate nephrons.
hemodilution (hypervolemia) however, ● Insert indwelling catheter, as indicated.
during prolonged failure, anemia ○ Catheterization excludes lower tract
frequently develops as a result of RBC obstruction and provides means of
loss. Other possible causes (active or accurate monitoring of urine output
occult hemorrhage) should also be during acute phase; however,
evaluated. indwelling catheterization may be
● Serial chest x-rays. contraindicated because of increased
○ Increased cardiac size, prominent risk of infection.
pulmonary vascular markings, pleural ● Prepare for dialysis as indicated: hemodialysis,
effusion, congestion indicate acute peritoneal dialysis, or continuous renal
responses to fluid overload or chronic replacement therapy (CRRT).
changes associated with renal and heart ○ Done to correct volume overload,
failure. electrolyte and acid-base imbalances,
● Administer and/or restrict fluids as indicated. and to remove toxins. The type of
○ Fluid management is usually calculated dialysis chosen for ARF depends on the
to replace output from all sources plus degree of hemodynamic compromise
estimated insensible losses and patient’s ability to withstand the
(metabolism, diaphoresis). Prerenal procedure.
failure (azotemia) is treated with ● During peritoneal dialysis, position the patient
volume replacement and/or carefully: elevate the head of the bed.
vasopressors. The oliguric patient with ○ Doing so would reduce the pressure on
adequate circulating volume or fluid the diaphragm and can aid in
overload who is unresponsive to fluid respiration.
restriction and diuretics requires ● Watch out for complications such as peritonitis,
dialysis. Note: During oliguric phase, atelectasis, hypokalemia, pneumonia and/or
“push/pull” therapy (push IV fluids and shock.
diurese with diuretics) may be tried to ○ These complications are common for
stimulate kidney function. patients undergoing peritoneal dialysis.
● Administer medication as indicated:
○ Diuretics: furosemide (Lasix),
bumetanide (Bumex), torsemide Risk for decreased cardiac output
(Demadex), mannitol (Osmitrol). Risk factors may include
■ Given early in oliguric phase ● Fluid overload (kidney dysfunction/failure,
of ARF in an effort to convert overzealous fluid replacement)
to non-oliguric phase, flush ● Fluid shifts, fluid deficit (excessive losses)
the tubular lumen of debris, ● Electrolyte imbalance (potassium, calcium);
reduce hyperkalemia, and severe acidosis
promote adequate urine ● Uremic effects on cardiac muscle/oxygenation
volume. Desired Outcomes
○ Antihypertensives: Maintain cardiac output as evidenced by BP and
clonidine(Catapres), methyldopa HR/rhythm within patient’s normal limits; peripheral
(Aldomet), prazosin (Minipress). pulses strong and equal with adequate capillary refill
■ May be given to treat time.
hypertension by counteracting Nursing Interventions
effects of decreased renal ● Monitor BP and HR.
blood flow and/or circulating ○ Fluid volume excess, combined with
volume overload. hypertension (common in renal failure)
○ Calcium channel blockers. and effects of uremia, increases cardiac
■ Given early in nephrotoxic workload and can lead to cardiac
ATN to reduce influx of failure. In ARF, cardiac failure is
calcium into kidney cells, usually reversible.
thereby helping to maintain ● Observe ECG or telemetry for changes in
cell integrity and improve rhythm.

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○ Changes in electromechanical function ○ Potassium.

may become evident in response to ■ During oliguric phase,
progressing renal failure and hyperkalemia is present but
accumulation of toxins and electrolyte often shifts to hypokalemia in
imbalance. Peaked T wave, wide QRS, diuretic or recovery phase.
prolonged PR interval is usually Any potassium value
associated with hyperkalemia. Flat T associated with ECG changes
wave, peaked P wave, and appearance requires intervention. Note: A
of the U waves usually indicate serum level of 6.5 mEq or
hypokalemia. Prolonged QT interval higher constitutes a medical
may reflect calcium deficit. emergency.
● Auscultate heart sounds. ○ Calcium.
○ Development of S3/S4 is indicative of ■ In addition to its own cardiac
failure. Pericardial friction rub may be effects, calcium deficit
only manifestation of uremic enhances the toxic effects of
pericarditis, requiring prompt potassium.
intervention and possibly acute dialysis. ○ Magnesium.
● Assess color of skin, mucous membranes, and ■ Dialysis or calcium
nail beds. administration may be
○ Note capillary refill time. Pallor may necessary to combat the
reflect vasoconstriction or anemia. CNS-depressiveeffects of an
Cyanosis is a late sign and is related to elevated serum magnesium
pulmonary congestion and/or cardiac level.
failure. ● Administer and/or restrict fluids as indicated.
● Note occurrence of slow pulse, hypotension, ○ Cardiac output depends on circulating
flushing, nausea and vomiting, and depressed volume (affected by both fluid excess
level of consciousness. and deficit) and myocardial muscle
○ Use of drugs (like antacids) containing function.
magnesium can result in ● Provide supplemental oxygen if indicated.
hypermagnesemia, potentiating the ○ Maximizes available oxygen for
neuromuscular dysfunction and risk of myocardial uptake to reduce cardiac
a respiratory or cardiac arrest. Use workload and cellular hypoxia.
aluminum-hydroxide-based antacid. ● Administer medications as indicated:
● Monitor for GI bleeding by guaiac testing all ○ Inotropic agents: digoxin (Lanoxin)
stools for blood. ■ May be used to improve
○ Gastrointestinal bleeding is a known cardiac output by increasing
complication of renal failure; however, myocardial contractility and
its pathogenesis remains uncertain. stroke volume. Dosage
Some have attributed gastrointestinal depends on renal function and
bleeding to the effects of uremia on the potassium balance to obtain
gastrointestinal mucosa; others have therapeutic effect without
suggested that uremia may affect toxicity.
platelet adhesiveness, which may ○ Calcium gluconate
explain the prolonged gastrointestinal ■ Serum calcium is often low
bleeding seen in patients with renal but usually does not require
failure. In addition, the role of specific treatment in ARF.
heparinization and the widespread use Calcium gluconate may be
of antiplatelet agents in patients on given to treat hypocalcemia
dialysis have been implicated in the and to offset the effects of
etiology of gastrointestinal bleeding. hyperkalemia by modifying
● Investigate reports of muscle cramps, numbness cardiac irritability.
of fingers, with muscle twitching, hyperreflexia. ○ Aluminum hydroxide gels
○ Neuromuscular indicators of (Amphojel, Basaljel)
hypocalcemia, which can also affect ■ Increased phosphate levels
cardiac contractility and function. may occur as a result of failure
● Maintain bed rest or encourage adequate rest and of glomerular filtration and
provide assistance with care and desired require use of
activities. phosphate-binding antacids to
○ Reduces oxygen consumption and limit phosphate absorption
cardiac workload. from the GI tract.
● Monitor laboratory studies: ○ Glucose and/or insulin solution

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BSN-4E2

■ Temporary measure to lower ○ The fasting or catabolic patient

serum potassium by driving normally loses 0.2–0.5 kg/day. Changes
potassium into cells when in excess of 0.5 kg may reflect shifts in
cardiac rhythm is endangered. fluid balance.
○ Sodium bicarbonate or sodium ● Monitor laboratory studies: BUN, albumin,
citrate transferrin, sodium, and potassium.
■ May be used to correct ○ Indicators of nutritional needs,
acidosis or hyperkalemia (by restrictions, and necessity for and
increasing serum pH) if patient effectiveness of therapy.
is severely acidotic and not ● Consult with dietitian support team.
suffering from fluid overload. ○ Determines individual calorie and
○ Sodium polystyrene sulfonate nutrient needs within the restrictions,
(Kayexalate) with or without sorbitol. and identifies most effective route and
■ Exchange resin trades sodium product (oral supplements, enteral or
for potassium in the GI tract to parenteral nutrition).
lower serum potassium level. ● Provide high-calorie, low to moderate protein
Sorbitol may be included to diet. Include complex carbohydrates and fat
cause osmotic diarrhea to help sources to meet caloric needs and essential
excrete potassium. amino acids. Avoid concentrated sugar sources.
Give anorectic patients small, frequent meals.
○ The amount of needed exogenous
Nutrition: imbalanced, risk for less than body protein is less than normal unless
requirements patient is on dialysis. Carbohydrates
Risk factors may include meet energy needs and limit tissue
● Protein catabolism; dietary restrictions to reduce catabolism, preventing keto acid
nitrogenous waste products formation from protein and fat
● Increased metabolic needs oxidation. Carbohydrate intolerance
● Anorexia, nausea/vomiting; ulcerations of oral mimicking DM may occur in severe
mucosa renal failure. Essential amino acids
Desired Outcomes improve nitrogen balance and
Maintain/regain weight as indicated by individual nutritional status, stimulate repair of
situation, free of edema. tubular epithelial cells, and enhance
Nursing Implementation patient’s ability to fight systemic
● Assess and document dietary intake. complications.
○ Aids in identifying deficiencies and ● Maintain proper electrolyte balance by strictly
dietary needs. General physical monitoring levels.
condition, uremic symptoms (nausea, ○ Medications and decrease in GFR can
anorexia), and multiple dietary cause electrolyte imbalances and may
restrictions affect food intake. further cause renal injury.
● Provide frequent, small feedings. ● Restrict potassium, sodium, and phosphorus
○ Minimizes anorexia and nausea intake as indicated.
associated with uremic state and/or ○ Restriction of these electrolytes may be
diminished peristalsis. needed to prevent further renal damage,
● Give patient/SO a list of permitted foods or especially if dialysis is not part of
fluids and encourage involvement in menu treatment, and/or during recovery phase
choices. of ARF.
○ Provides patient with a measure of ● Administer medications as indicated:
control within dietary restrictions. Food ○ Iron preparations
from home may enhance appetite. ■ Iron deficiency may occur if
● Offer frequent mouth care or rinse with diluted protein is restricted, patient is
acetic acid solution. anemic, or GI function is
○ Give gums, hard candy, breath mints impaired.
between meals. Mucous membranes ○ Calcium carbonate
may become dry and cracked. Mouth ■ Restores normal serum levels
care soothes, lubricates, and helps to improve cardiac and
freshen mouth taste, which is often neuromuscular function, blood
unpleasant because of uremia and clotting, and bone metabolism.
restricted oral intake. Rinsing with Note: Low serum calcium is
acetic acid helps neutralize ammonia often corrected as phosphate
formed by conversion of urea. absorption is decreased in the
● Weigh daily. GI system. Calcium may be

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Cruz, Larraine Jhasmine D.
BSN-4E2

substituted as a phosphate ○ Although elevated WBCs may indicate

binder. generalized infection, leukocytosis is
○ Vitamin D commonly seen in ARF and may reflect
■ Necessary to facilitate injury within the kidney. A shifting of
absorption of calcium from the the differential to the left is indicative
GI tract. of infection.
○ B complex and C vitamins, folic acid ● Obtain specimen(s) for culture and sensitivity
■ Vital as coenzyme in cell and administer appropriate antibiotics as
growth and actions. Intake is indicated.
decreased because of protein ○ Verification of infection and
restrictions. identification of specific organism aids
○ Antiemetics: prochlorperazine in choice of the most effective
(Compazine), trimethobenzamide treatment. Note: A number of
(Tigan). anti-infective agents require
■ Given to relieve N/V and may adjustments of dose and/or time while
enhance oral intake. renal clearance is impaired.

Risk for Infection Risk for Deficient Fluid Volume

Risk factors may include Risk factors may include
● Depression of immunologic defenses (secondary ● Excessive loss of fluid (diuretic phase of ARF,
to uremia) with rising urinary volume and delayed return of
● Invasive procedures/devices (e.g., urinary tubular reabsorption capabilities)
catheterization) Desired Outcomes
● Changes in dietary intake/malnutrition Display I&O near balance; good skin turgor, moist
Desired Outcomes mucous membranes, palpable peripheral pulses, stable
Experience no signs/symptoms of infection. weight and vital signs, electrolytes within normal range.
Nusing Intervention Nursing Interventions
● Promote good hand washing by patient and staff. ● Measure I&O accurately. Weigh daily. Calculate
○ Reduces risk of cross contamination. insensible fluid losses.
● Avoid invasive procedures, instrumentation, and ○ Assessment can help estimate fluid
manipulation of indwelling catheters whenever replacement needs. Fluid intake should
possible. Use aseptic technique when caring and approximate losses through urine,
manipulating IV and invasive lines. Change site nasogastric or wound drainage, and
dressings per protocol. Note edema, purulent insensible water losses (diaphoresis,
drainage. metabolism).
○ Limits introduction of bacteria into ● Provide allowed fluids throughout 24-hr period.
body. Early detection of developing ○ Diuretic phase of ARF may revert to
infection may prevent sepsis. oliguric phase if fluid intake is not
● Provide routine catheter care and promote maintained or nocturnal dehydration
meticulous perineal care. occurs.
○ Keep urinary drainage system closed ● Monitor BP (noting postural changes) and HR.
and remove indwelling catheter as soon ○ Orthostatic hypotension and
as possible. Reduces bacterial tachycardia suggest hypovolemia.
colonization and risk of ascending UTI. ● Note signs and symptoms of dehydration: dry
● Encourage deep breathing, coughing, frequent mucous membranes, thirst, dulled sensorium,
position changes. peripheral vasoconstriction.
○ Prevents atelectasis and mobilizes ○ In diuretic or postobstructive phase of
secretions to reduce risk of pulmonary renal failure, urine output can exceed 3
infections. L/day. Extracellular fluid volume
● Assess skin integrity. depletion activates the thirst center, and
○ Excoriations from scratching may sodium depletion causes persistent
become secondarily infected. thirst, unrelieved by drinking water.
● Monitor vital signs. Continued fluid losses including
○ Fever (higher than 100.4°F) with inadequate replacement may lead to
increased pulse and respirations is hypovolemic state.
typical of increased metabolic rate ● Control environmental temperature; limit bed
resulting from inflammatory process, linens as indicated.
although sepsis can occur without a ○ May reduce diaphoresis, which
febrile response. contributes to overall fluid losses.
● Monitor WBC count with differential. ● Monitor laboratory studies

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Cruz, Larraine Jhasmine D.
BSN-4E2

○ In nonoliguric ARF or in diuretic phase procedures that patient may undergo.

of ARF, large urine losses may result in ● Review fluid restriction. Remind patient to
sodium wasting while elevated urinary spread fluids over entire day and to include all
sodium acts osmotically to increase fluids (ice) in daily fluid counts.
fluid losses. Restriction of sodium may ○ Depending on the cause and stage of
be indicated to break the cycle. ARF, patient may need to either restrict
or increase intake of fluids.
● Discuss activity restriction and gradual
Deficient Knowledge resumption of desired activity. Encourage use of
May be related to energy-saving, relaxation, and diversional
● Lack of exposure/recall techniques.
● Information misinterpretation ○ Patient with severe ARF may need to
● Unfamiliarity with information resources restrict activity and/or may feel weak
Possibly evidenced by for an extended period during lengthy
● Questions/request for information, statement of recovery phase, requiring measures to
misconception conserve energy and reduce boredom.
● Inaccurate follow-through of ● Discuss reality of continued presence of fatigue.
instructions/development of preventable ○ Decreased metabolic energy
● Complications production, presence of anemia, and
Desired Outcomes states of discomfort commonly result in
● Verbalize understanding of condition/disease fatigue.
process, prognosis, and potential complications. ● Determine ADLs and personal responsibilities.
● Identify relationship of signs/symptoms to the Identify available resources and support
disease process and correlate symptoms with systems.
causative factors. ○ Helps patient manage lifestyle changes
● Verbalize understanding of therapeutic needs. and meet personal needs.
● Initiate necessary lifestyle changes and ● Recommend scheduling activities with adequate
participate in treatment regimen. rest periods.
Nursing Interventions ○ Prevents excessive fatigue and
● Review disease process, prognosis, and conserves energy for healing, tissue
precipitating factors if known. regeneration.
○ Provides knowledge base from which ● Review use of medication. Encourage patient to
patient can make informed choices. discuss all medications and herbal supplements
● Explain level of renal function after acute with physician.
episode is over. ○ Medications that are concentrated in
○ Patient may experience residual defects and/or excreted by the kidneys can
in kidney function, which may or may cause toxic cumulative reactions and/or
not be permanent. permanent damage to kidneys. Some
● Discuss renal dialysis or transplantation if these supplements may interact with
are likely options for the future. prescribed medications and may
○ Although these options would have electrolytes.
been previously presented by the ● Stress necessity of follow-up care, laboratory
physician, patient may now be at a studies.
point when options need to be ○ Renal function may be slow to return
considered and may desire additional following acute failure (up to 12 mo),
input. and deficits may persist, requiring
● Review dietary plan and restrictions. Include changes in therapy to avoid recurrence.
fact sheet listing food restrictions. ● Identify symptoms requiring medical
○ Adequate nutrition is necessary to intervention: decreased urinary output, sudden
promote tissue healing; adherence to weight gain, presence of edema, lethargy,
restrictions may prevent complications. bleeding, signs of infection, altered mentation.
● Encourage patient to observe characteristics of ○ Prompt evaluation and intervention
urine and amount, frequency of output. may prevent serious complications or
○ Changes may reflect alterations in renal progression to chronic renal failure.
function and need for dialysis. ●
● Establish regular schedule for weighing.
○ Useful tool for monitoring fluid and
dietary needs.
● Provide emotional support to the patient and
family.
○ To reassure them of the all the

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Cruz, Larraine Jhasmine D.
BSN-4E2

Chronic Renal Failure Respiratory Failure and Acute Kidney Injury

Chronic kidney disease (CKD) is a long-term condition There is a significant association between kidney failure
where the kidneys don't work as well as they should. and respiratory failure.12 Positive-pressure ventilation
It's a common condition often associated with getting reduces blood flow to the kidney, which can lower the
older. It can affect anyone, but it's more common in people GFR and decrease urine output. These effects are
who are black or of south Asian origin. intensified with the addition of positive end-expiratory
CKD can get worse over time and eventually the kidneys pressure.12 Patients with chronic lung conditions such as
may stop working altogether, but this is uncommon. Many chronic obstructive pulmonary disease have a 41%
people with CKD are able to live long lives with the increased risk of death if they also have AKI.
condition. Management recommendations for patients with lung
Chronic kidney disease (CKD) means that the kidneys disease and AKI include lung protective ventilation, a
are damaged and can’t filter blood the way they should. conservative fluid management strategy, and early
The disease is called “chronic” because the damage to the recognition and treatment of pulmonary infections.
kidneys happens slowly over a long period of time. This Sepsis and Acute Kidney Injury
damage can cause wastes to build up in the human body. Sepsis causes almost half of cases of AKI in critically ill
CKD can also cause other health problems. patients. Sepsis and septic shock create hemodynamic
instability and reduce perfusion to the kidney. In severely
septic patients, inflammation increases vascular
permeability, and much of this fluid may move into the
third space (interstitial space). In septic shock,
vasopressors are used after volume resuscitation.
Vasopressors raise blood pressure and increase systemic
vascular resistance, but they also may raise the vascular
resistance within the kidney microvasculature.
Trauma and Acute Kidney Injury
Traumatically injured patients often have a different
demographic profile than other critical care populations.
This is because patients with a traumatic injury are
always emergency admissions, are often younger and
male, and may have fewer coexisting illnesses.
There is a strong association between kidney failure and
A person may be are at risk for kidney disease if they have:
heart failure. Heart kidney interactions have been
● Diabetes. Diabetes is the leading cause of CKD.
categorized into five types under the term cardiorenal
High blood glucose, also called blood sugar, from
syndrome (CRS):
diabetes can damage the blood vessels in your
● Type 1 CRS: Acute heart failure that results in
kidneys. Almost 1 in 3 people with diabetes has
AKI
CKD.
● Type 2 CRS: Chronic heart failure that results in
● High blood pressure. High blood pressure is the
AKI
second leading cause of CKD. Like high blood
● Type 3 CRS: AKI that results in acute heart failure
glucose, high blood pressure also can damage the
● Type 4 CRS: CKD that results in chronic heart
blood vessels in a person's kidneys. Almost 1 in 5
failure
adults with high blood pressure has CKD.
● Type 5 CRS: A systemic condition that damages
● Heart disease. Research shows a link between
both the heart and kidney; examples include
kidney disease and heart disease. People with heart
amyloidosis, sepsis, and liver cirrhosis
disease are at higher risk for kidney disease, and
Several risk factors for atherosclerotic cardiovascular
people with kidney disease are at higher risk for
disease also affect the kidneys, notably hypertension and
heart disease. Researchers are working to better
diabetes. Maintenance of blood pressure below 130/80 mm
understand the relationship between kidney disease
Hg and blood glucose within the normal range decreases the
and heart disease.
risk of developing both CKD and the atherosclerotic cardiac
● Family history of kidney failure. If the patient
diseases such as coronary artery disease and peripheral
mother, father, sister, or brother has kidney failure,
artery disease. A treatment challenge often encountered in
the patient will be at risk for CKD. Kidney disease
CRS is diuretic resistance to loop diuretics.
tends to run in families. If the patient have kidney
disease, encourage family members to get tested.

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BSN-4E2
● The chances of having kidney disease increase with ● weight loss and poor appetite
age. The longer a person have had diabetes, high ● swollen ankles, feet or hands – as a result of water
blood pressure, or heart disease, the more likely retention (oedema)
that a person will have kidney disease. ● shortness of breath
● African Americans, Hispanics, and American ● tiredness
Indians tend to have a greater risk for CKD. The ● blood in your pee (urine)
greater risk is due mostly to higher rates of diabetes ● an increased need to pee – particularly at night
and high blood pressure among these groups. ● difficulty sleeping (insomnia)
Scientists are studying other possible reasons for ● itchy skin
this increased risk. ● muscle cramps
The top three causes of CKD (in order of incidence) are ● feeling sick
diabetes, hypertension, and glomerulonephritis. Diabetes ● headaches
and hypertension cause approximately 70% of CKD cases. ● erectile dysfunction in men
Other risk factors include: This stage of CKD is known as kidney failure, end-stage
● congenital abnormalities (for example, poly­cystic renal disease or established renal failure. It may eventually
kidney disease, Alport syndrome, sickle cell require treatment with dialysis or a kidney transplant
disease) Chronic kidney disease (CKD) can be diagnosed with
● urinary tract or systemic infections blood and urine tests.
● family history of CKD In many cases, CKD is only found when a routine blood or
● urinary or kidney stones urine test that a person have for another problem shows that
● history of acute kidney injury or failure the kidneys may not be working normally.
● urinary tract obstruction A person must see a consult to his/her doctor if persistent
● autoimmune disease (for example, scleroderma, symptoms of CKD, such as:
systemic lupus erythematosus) ● weight loss or poor appetite
● nephrotoxin exposure from sources such as ● swollen ankles, feet or hands
over-the-counter pain medications (for example, ● shortness of breath
aspirin or ibuprofen), prescribed pain relievers (for ● tiredness
example, oxycodone or naproxen), other ● blood in your pee (urine)
medications (for example, antibiotics or ● peeing more than usual, particularly at night
antineoplastics), pesticides, and heavy metals (for The doctor can look for other possible causes and arrange
example, lead, mercury, or arsenic) tests if necessary.
● age 60 or older and ethnicity (African American, Because CKD often has no symptoms in the early stages,
American Indian, Asian, Pacific Islander, or some people at a higher risk should be tested regularly.
Hispanic). Regular testing is recommended if a person have:
Early-stage CKD can be asymptomatic, so recognizing risk ● high blood pressure
factors and alerting patients and providers to them is crucial ● diabetes
for prevention, early diagnosis, and optimal disease ● acute kidney injury – sudden damage to the kidneys
management. that causes them to stop working properly
Clinical manifestations ● cardiovascular disease – conditions that affect the
Early stages of CKD heart, arteries and veins, such as coronary heart
Kidney disease does not tend to cause symptoms when it's disease or heart failure
at an early stage. ● other conditions that can affect the kidneys – such
This is because the body is usually able to cope with a as kidney stones, an enlarged prostate or lupus
significant reduction in kidney function. ● a family history of advanced CKD or an inherited
Kidney disease is often only diagnosed at this stage if a kidney disease
routine test for another condition, such as a blood or urine ● protein or blood in your urine where there's no
test, detects a possible problem. known cause
If it's found at an early stage, medicine and regular tests to A person is also more likely to develop kidney disease if
monitor it may help stop it becoming more advanced. they are black or of south Asian origin.
Later stages of CKD Person taking long-term medicines that can affect the
A number of symptoms can develop if kidney disease is not kidneys, such as lithium, omeprazole or non-steroidal
found early or it gets worse despite treatment. anti-inflammatory drugs (NSAIDs), should also be tested
Symptoms can include: regularly.

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BSN-4E2
Diagnostic Tests
The main treatments are:
Blood test
The main test for kidney disease is a blood test. The test ● lifestyle changes – to help you stay as healthy as
measures the levels of a waste product called creatinine in possible
a persons blood. ● medicine – to control associated problems, such as
The doctor uses the blood test results, plus the age, size, high blood pressure and high cholesterol
gender and ethnic group to calculate how many millilitre ● dialysis – treatment to replicate some of the
of waste a persons kidneys should be able to filter in a kidney's functions, which may be necessary in
minute.
advanced (stage 5) CKD
This calculation is known as the estimated glomerular
filtration rate (eGFR). ● kidney transplant – this may also be necessary in
Healthy kidneys should be able to filter more than advanced (stage 5) CKD.
90ml/min. A person may have CKD if the rate is lower Medicine
than this. There's no medicine specifically for CKD, but medicine can
Urine test help control many of the problems that cause the condition
A urine test is also done to:
and the complications that can happen as a result of it. A
● check the levels of substances called albumin
and creatinine in person's urine – known as the person may need to take medicine to treat or prevent the
albumin:creatinine ratio, or ACR different problems caused by CKD.
● check for blood or protein in urine High blood pressure
Alongside the eGFR, urine tests can help give a more
Good control of blood pressure is vital to protect the
accurate picture of how well the kidneys are working.
Other tests kidneys.
Sometimes other tests are also used to assess the level of People with kidney disease should usually aim to get their
damage to the kidneys. blood pressure down to below 140/90mmHg, but they
These may include: should aim to get it down to below 130/80mmHg if they
● an ultrasound scan, MRI scan or CT scan – to also have diabetes.
see what the kidneys look like and check
There are many types of blood pressure medicines, but
whether there are any blockages
● a kidney biopsy – a small sample of kidney medicines called angiotensin converting enzyme (ACE)
tissue is removed using a needle and the cells are inhibitors are often used. Examples include ramipril,
examined under a microscope for signs of enalapril and lisinopril.
damage Side effects of ACE inhibitors can include:
The test results can be used to determine how damaged ● a persistent dry cough
the kidneys are, known as the stage of CKD. ● dizziness
This can help the care provider or doctor decide the best
● tiredness or weakness
treatment for the person and how often they should have
tests to monitor the current condition. ● headaches
The eGFR results is given as a stage from 1 of 5: If the side effects of ACE inhibitors are particularly
● stage 1 (G1) – a normal eGFR above 90ml/min, troublesome, they can be given a medicine called an
but other tests have detected signs of kidney angiotensin-II receptor blocker (ARB) instead.
damage High Cholesterol
● stage 2 (G2) – a slightly reduced eGFR of 60 to People with CKD have a higher risk of cardiovascular
89ml/min, with other signs of kidney damage
disease, including heart attack and stroke. This is because
● stage 3a (G3a) – an eGFR of 45 to 59ml/min
● stage 3b (G3b) – an eGFR of 30 to 44ml/min some of the causes of kidney disease are the same as
● stage 4 (G4) – an eGFR of 15 to 29ml/min those for cardiovascular disease, including high blood
● stage 5 (G5) – an eGFR below 15ml/min, pressure and high cholesterol. They may be prescribed
meaning the kidneys have lost almost all of their medicines called statins to reduce the risk of developing
function cardiovascular disease. Examples include atorvastatin and
The ACR result is given as a stage from 1 to 3:
simvastatin.
● A1 – an ACR of less than 3mg/mmol
● A2 – an ACR of 3 to 30mg/mmol Side effects of statins can include:
● A3 – an ACR of more than 30mg/mmol ● headaches
For both eGFR and ACR, a higher stage indicates more ● feeling sick
severe kidney disease. ● constipation or diarrhoea
Medical Management ● muscle and joint pain
There's no cure for chronic kidney disease (CKD), but Water Retention
treatment can help relieve the symptoms and stop it getting A person may get swelling in their ankles, feet and hands
worse. The treatment will depend on the stage of CKD. if they have kidney disease. This is because their kidneys

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Cruz, Larraine Jhasmine D.
BSN-4E2
on a person skin and small electrical impulses are sent to
are not as effective at removing fluid from your blood,
weak muscles, usually in an arms or legs.
causing it to build up in body tissues (edema). They may
Dialysis
be advised to reduce your daily salt and fluid intake,
For a small proportion of people with CKD, the kidneys will
including fluids in food such as soups and yoghurts, to
eventually stop working. This usually hapens gradually, so
help reduce the swelling. In some cases they may also be
there should be time to plan the next stage of your treatment.
given diuretics (tablets to help urinate more), such as
One of the options when CKD reaches this stage is dialysis.
furosemide.
This is a method of removing waste products and excess
Side effects of diuretics can include dehydration and
fluid from the blood.
reduced levels of sodium and potassium in the blood.
There are 2 main types of dialysis:
Anaemia
● hemodialysis – this involves diverting blood into
Many people with advanced-stage CKD develop
an external machine, where it's filtered before being
anaemia, which is a lack of red blood cells.
returned to the body
Symptoms of anaemia include:
● peritoneal dialysis – this involves pumping
● tiredness
dialysis fluid into a space inside your tummy to
● lack of energy
draw out waste products from the blood as they
● shortness of breath
pass through vessels lining the inside of your
● a pounding, fluttering or irregular heartbeat
tummy
(palpitations)
○ Can be brought home
If a person have anaemia, they may be given injections of
Hemodialysis is usually done about 3 times a week, either at
a medicine called erythropoietin. This is a hormone that
hospital or at home. Peritoneal dialysis is normally done at
helps their body produce more red blood cells. If they
home several times a day, or overnight.
have an iron deficiency as well, iron supplements may
also be recommended.
Bone problems
If a person's kidneys are severely damaged, they can get a
build-up of phosphate in their body because the kidneys
cannot get rid of it. Along with calcium, phosphate is
important for maintaining healthy bones. But if the
phosphate level rises too much, it can upset the balance of
calcium in the body and lead to thinning of the bones.
A person may be advised to limit the amount food which
are high in phosphate, such as red meat, dairy products,
eggs and fish. If this does not lower the phosphate level
enough, they may be given medicines called phosphate
binders. Commonly used medicines include calcium
acetate and calcium carbonate. Some people with CKD
also have low levels of vitamin D, which is necessary for
healthy bones. If they have low in vitamin D, they may be
Kidney Transplant
given a supplement called colecalciferol or ergocalciferol
An alternative to dialysis for people with severely reduced
to boost your vitamin D level.
kidney function is a kidney transplant. This is often the most
Glomerulonephritis
effective treatment for advanced kidney disease, but it
Kidney disease can be caused by inflammation of the
involves major surgery and taking medicines
filters inside the kidneys, known as glomerulonephritis.
(immunosuppressants) for the rest of your life to stop your
In some cases this happens as a result of the immune
body attacking the donor organ.
system mistakenly attacking the kidneys. If a kidney
A person can live with one kidney, which means donor
biopsy finds this is the cause of your kidney problems,
kidneys can come from living or recently deceased donors.
they may be prescribed medicine to reduce the activity of
But there's still a shortage of donors, and a person could
the immune system, such as a steroid or a medicine called
wait months or years for a transplant. They - a person with
cyclophosphamide.
CKD may need to have dialysis while waiting for a
Improving Muscle Strength transplant.
If a person is having a bad flare-up and are unable to Survival rates for kidney transplants are very good. About
exercise, they may be offered electrical stimulation to make 90% of transplants still function after 5 years and many
their muscles stronger. This is where electrodes are placed work usefully after 10 years or more.
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BSN-4E2

pericarditis, potentiating risk of

pericardial effusion or tamponade.
● Evaluate heart sounds (note friction rub), BP,
peripheral pulses, capillary refill, vascular
congestion, temperature, and sensorium or
mentation.
○ Presence of sudden hypotension,
paradoxic pulse, narrow pulse pressure,
diminished or absent peripheral pulses,
marked jugular distension, pallor, and a
rapid mental deterioration indicate
tamponade, which is a medical
emergency.
Nursing Management ● Assess activity level, response to activity.
The nursing care planning goal for with chronic renal failure ○ Weakness can be attributed to HF and
is to prevent further complications and supportive care. anemia.
● Monitor laboratory and diagnostic studies:
Client education is also critical as this is a chronic disease
Electrolytes (potassium, sodium, calcium,
and thus requires long-term treatment. magnesium), BUN and Cr;
Risk for Decreased Cardiac Output ○ Imbalances can alter electrical
Risk factors may include conduction and cardiac function.
● Fluid imbalances affecting circulating volume, ● Chest x-rays.
myocardial workload, and systemic vascular ○ Useful in identifying developing
resistance (SVR) cardiac failure or soft-tissue
● Alterations in rate, rhythm, cardiac conduction calcification.
(electrolyte imbalances, hypoxia) ● Administer antihypertensive drugs such as
● Accumulation of toxins (urea), soft-tissue prazosin (Minipress), captopril (Capoten),
calcification (deposition of calcium phosphate) clonidine (Catapres), hydralazine (Apresoline).
Desired Outcomes ○ Reduces systemic vascular resistance
Maintain cardiac output as evidenced by BP and heart and renin release to decrease
rate within patient’s normal range; peripheral pulses myocardial workload and aid in
strong and equal with prompt capillary refill time. prevention of HF and MI.
Nursing Interventions ● Prepare for dialysis.
● Auscultate heart and lung sounds. ○ Reduction of uremic toxins and
○ Evaluate presence of peripheral edema, correction of electrolyte imbalances and
vascular congestion and reports of fluid overload may limit and prevent
dyspnea.S3 and S4 heart sounds with cardiac manifestations, including
muffled tones, tachycardia, irregular hypertension and pericardial effusion.
heart rate, tachypnea, dyspnea, ● Assist with pericardiocentesis as indicated.
crackles, wheezes,edema and jugular ○ Accumulation of fluid within
distension suggest HF. pericardial sac can compromise cardiac
● Assess presence and degree of hypertension: filling and myocardial contractility,
monitor BP; note postural changes (sitting, impairing cardiac output and
lying, standing). potentiating risk of cardiac arrest.
○ Significant hypertension can occur
because of disturbances in the
renin-angiotensin-aldosterone system Risk for Ineffective Protection
(caused by renal dysfunction). ● Risk factors may include
Although hypertension is common, ● Abnormal blood profile (suppressed
orthostatic hypotension may occur erythropoietin production/secretion; decreased
because of intravascular fluid deficit, RBC production and survival; altered clotting
response to effects of antihypertensive factors; increased capillary fragility)
medications, or uremic pericardial Desired Outcomes
tamponade. Experience no signs/symptoms of bleeding/hemorrhage.
● Investigate reports of chest pain, noting location, Maintain/demonstrate improvement in laboratory values.
radiation, severity (0–10 scale), and whether or Nursing Intervention
not it is intensified by deep inspiration and ● Note reports of increasing fatigue, weakness.
supine position. ○ Observe for tachycardia, pallor of ski
○ Although hypertension and chronic HF and mucous membranes, dyspnea, and
may cause MI, approximately half of chest pain. Plan patient activities to
CRF patients on dialysis develop avoid fatigue. May reflect effects of

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

anemia and cardiac response necessary indicated.

to keep cells oxygenated. ○ May be necessary when patient is
● Monitor level of consciousness and behavior. symptomatic with anemia. PRCs are
○ Anemia may cause cerebral hypoxia usually given when patient is
manifested by changes in mentation, experiencing fluid overload or
orientation, and behavioral responses. receiving dialysis treatment. Washed
● Evaluate response to activity, ability to perform RBCs are used to prevent hyperkalemia
tasks. Assist as needed and develop schedule for associated with stored blood.
rest. ● Administer medications, as indicated:
○ Anemia decreases tissue oxygenation ○ Erythropoietin preparations
and increases fatigue, which may (Epogen, EPO, Procrit);
require intervention, changes in ■ Corrects many of the
activity, and rest. symptoms of CRF resulting
● Limit vascular sampling, combine laboratory from anemia by stimulating
tests when possible. the production and
○ Recurrent or excessive blood sampling maintenance of RBCs, thus
can worsen anemia. decreasing the need for
● Observe for oozing from venipuncture sites, transfusion.
bleeding, ecchymotic areas following slight ○ Iron preparations: folic acid
trauma, petechiae; joint swelling or mucous (Folvite), cyanocobalamin
membrane involvement (bleeding gums, (Rubisol-1000);
recurrent epistaxis, hematemesis, melena, and ■ Useful in managing
hazy or red urine. symptomatic anemia related to
○ Bleeding can occur easily because of nutritional or dialysis-induced
capillary fragility and altered clotting deficits. Note: Iron should not
functions and may worsen anemia. be given with phosphate
● Hematest GI secretions and stool for blood. binders because they may
○ Mucosal changes and altered platelet decrease iron absorption.
function due to uremia may result in ○ Cimetidine (Tagamet), ranitidine
gastric mucosal erosion and GI (Zantac); antacids;
hemorrhage. ■ May be given prophylactically
● Provide soft toothbrush, electric razor; use to reduce or neutralize gastric
smallest needle possible and apply prolonged acid and thereby reduce the
pressure following injections or vascular risk of GI hemorrhage.
punctures. ○ Hemostatics or fibrinolysis inhibitors
○ Reduces risk of bleeding and hematoma such as aminocaproic acid (Amicar);
formation. ■ Inhibits bleeding that does not
● Monitor laboratory studies: subside spontaneously or
○ RBCs, Hb and Hct; respond to usual treatment.
■ Uremia (elevated ammonia, ○ Stool softeners (Colace); bulk
urea, other toxins) decreases laxative (Metamucil).
production of erythropoietin ■ Straining to pass hard-formed
and depresses RBC production stool increases likelihood of
and survival time. In CRF, Hb mucosal and rectal bleeding.
and Hct are usually low but
tolerated; (patient may not be
symptomatic until Hb is below Disturbed Thought Process
7). May be related to
○ Platelet count, clotting factors; ● Physiological changes: accumulation of toxins
■ Suppression of platelet (e.g., urea, ammonia), metabolic acidosis,
formation and inadequate hypoxia; electrolyte imbalances, calcifications in
levels of factors III and VIII the brainLinks to an external site.
impair clotting and potentiate Possibly evidenced by
risk of bleeding. Note: ● Disorientation to person, place, time
Bleeding may become ● Memory deficit; altered attention span,
intractable in ESRD. decreased ability to grasp ideas
○ Prothrombin time (PT) level. ● Impaired ability to make decisions,
■ Abnormal prothrombin problem-solve
consumption lowers serum ● Changes in sensorium: somnolence, stupor,
levels and impairs clotting. coma
● Administer fresh blood, packed RBCs (PRCs) as ● Changes in behavior: irritability, withdrawal,

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Cruz, Larraine Jhasmine D.
BSN-4E2

depression, psychosis or mentation.

Desired Outcomes ● Provide supplemental O2 as indicated.
● Regain/maintain optimal level of mentation. ○ Correction of hypoxia alone can
● Identify ways to compensate for cognitive improve cognition.
impairment/memory deficits. ● Avoid use of barbiturates and opiates.
Nursing Interventions ○ Drugs normally detoxified in the
● Assess extent of impairment in thinking ability, kidneys will have increased half-life
memory, and orientation. Note attention span. and cumulative effects, worsening
○ Uremic syndrome’s effect can begin confusion.
with minor confusion, irritability and ● Prepare for dialysis.
progress to altered personality or ○ Marked deterioration of thought
inability to assimilate information and processes may indicate worsening of
participate in care. Awareness of azotemia and general condition,
changes provides opportunity for requiring prompt intervention to regain
evaluation and intervention. homeostasis
● Ascertain from SO patient’s usual level of
mentation.
○ Provides comparison to evaluate Risk for Impaired Skin Integrity
progression and resolution of Risk factors may include
impairment. ● Altered metabolic state, circulation (anemia with
● Provide SO with information about patient’s tissue ischemia), and sensation (peripheral
status. neuropathy)
○ Some improvement in mentation may ● Alterations in skin turgor (edema/dehydration)
be expected with restoration of more ● Reduced activity/immobility
normal levels of BUN, electrolytes, and ● Accumulation of toxins in the skin
serum pH. Desired Outcomes
● Provide quiet or calm environment and judicious ● Maintain intact skin.
use of television, radio, and visitation. ● Demonstrate behaviors/techniques to prevent
○ Minimizes environmental stimuli to skin breakdown/injury.
reduce sensory overload and confusion Nursing Interventions
while preventing sensory deprivation. ● Inspect skin for changes in color, turgor,
● Reorient to surroundings, person, and so forth. vascularity. Note redness, excoriation. Observe
○ Provide calendars, clocks, outside for ecchymosis, purpura.
window. Provides clues to aid in ○ Indicates areas of poor circulation or
recognition of reality. breakdown that may lead to decubitus
● Present reality concisely, briefly, and do not formation and infection.
challenge illogical thinking. ● Monitor fluid intake and hydration of skin and
○ Confrontation potentiates defensive mucous membranes.
reactions and may lead to patient ○ Detects presence of dehydration or
mistrust and heightened denial of overhydration that affect circulation
reality. and tissue integrity at the cellular level.
● Communicate information and instructions in ● Inspect dependent areas for edema. Elevate legs
simple, short sentences. Ask direct, yes or no as indicated.
questions. Repeat explanations as necessary. ○ Edematous tissues are more prone to
○ May aid in reducing confusion, and breakdown. Elevation promotes venous
increases possibility that return, limiting venous stasis and
communications will be understood and edema formation.
remembered. ● Change position frequently; move patient
● Establish a regular schedule for expected carefully; pad bony prominences with sheepskin,
activities. elbow or heel protectors.
○ Aids in maintaining reality orientation ○ Decreases pressure on edematous,
and may reduce fear and confusion. poorly perfused tissues to reduce
● Promote adequate rest and undisturbed periods ischemia.
for sleep. ● Provide soothing skin care. Restrict use of soaps.
○ Sleep deprivation may further impair Apply ointments or creams (lanolin, Aquaphor).
cognitive abilities. ○ Baking soda, cornstarch baths decrease
● Monitor laboratory studies such as BUN and Cr, itching and are less drying than soaps.
serum electrolytes, glucose level, and Lotions and ointments may be desired
ABGs(Po2, pH). to relieve dry, cracked skin.
○ Correction of elevations or imbalances ● Keep linens dry, wrinkle-free.
can have profound effects on cognition ○ Reduces dermal irritation and risk of

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

skin breakdown. ● Recommend patient stop smoking and avoid

● Investigate reports of itching. lemon or glycerine products or mouthwash
○ Although dialysis has largely containing alcohol.
eliminated skin problems associated ○ These substances are irritating to the
with uremic frost, itching can occur mucosa and have a drying effect,
because the skin is an excretory route potentiating discomfort.
for waste products such as phosphate ● Provide artificial saliva as needed (Ora-Lube).
crystals (associated with ○ Prevents dryness, buffers acids, and
hyperparathyroidism in ESRD). promotes comfort.
● Recommend patient use cool, moist compresses ● Administer medications as indicated such as
to apply pressure (rather than scratch) pruritic antihistamines: cyproheptadine (Periactin).
areas. Keep fingernails short; encourage use of ○ May be given for relief of itching.
gloves during sleep if needed.
○ Alleviates discomfort and reduces risk
of dermal injury. Deficient Knowledge
● Suggest wearing loose-fitting cotton garments. May be related to
○ Prevents direct dermal irritation and ● Lack of exposure/recall, information
promotes evaporation of moisture on misinterpretation
the skin. ● Cognitive limitation
● Provide foam or flotation mattress. Possibly evidenced by
○ Reduces prolonged pressure on tissues, ● Questions/request for information, statement of
which can limit cellular perfusion, misconception
potentiating ischemia and necrosis. ● Inaccurate follow-through of instructions,
development of preventable complications
Desired Outcomes
Risk for Impaired Oral Mucous Membrane ● Verbalize understanding of condition/disease
Risk factors may include process and potential complications.
● Lack of/or decreased salivation, fluid restrictions ● Verbalize understanding of therapeutic needs.
● Chemical irritation, conversion of urea in saliva ● Correctly perform necessary procedures and
to ammonia explain reasons for the actions.
Desired Outcomes ● Demonstrate/initiate necessary lifestyle changes.
● Maintain integrity of mucous membranes. ● Participate in treatment regimen.
● Identify/initiate specific interventions to Nursing Interventions
promote healthy oral mucosa. ● Review disease process and prognosis and future
Nursing Interventions expectations.
● Inspect oral cavity; note moistness, character of ○ Provides knowledge base from which
saliva, presence of inflammation, ulcerations, patient can make informed choices.
leukoplakia. ● Review dietary restrictions, including:
● Provides opportunity for prompt intervention ○ Phosphorus (carbonated drinks,
and prevention of infection. processed foods, poultry, corn, peanuts)
● Provide fluids throughout 24-hr period within and magnesium (whole grain products,
prescribed limit. legumes); Retention of
○ Prevents excessive oral dryness from phosphorus stimulates the parathyroid
prolonged period without oral intake. glands to shift calcium from
● Offer frequent mouth care and rinse with 0.25% bones(renal osteodystrophy ) , and
acetic acid solution; provide gum, hard candy, accumulation of magnesium can impair
breath mints between meals. neuromuscular function and mentation.
○ Mucous membranes may become dry ○ Fluid and sodium restrictions when
and cracked. Mouth care soothes, indicated.If fluid retention is a problem,
lubricates, and helps freshen mouth patient may need to restrict intake of
taste, which is often unpleasant because fluid to 1100 cc (or less) and restrict
of uremia and restricted oral intake. dietary sodium. If fluid overload is
Rinsing with acetic acid helps present, diuretic therapy or dialysis will
neutralize ammonia formed by be part of the regimen.
conversion of urea. ● Discuss other nutritional concerns such as
● Encourage good dental hygiene after meals and regulating protein intake according to level of
at bedtime. Recommend avoidance of dental renal function (generally 0.6 – 0.7g per k of
floss. body weight per day of good quality protein,
○ Reduces bacterial growth and potential such as meat, eggs).
for infection. Dental floss may cut ○ Metabolites that accumulate in blood
gums, potentiating bleeding. derive almost entirely from protein

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

catabolism; as renal function declines, ○ Peripheral neuropathy may develop,

proteins may be restricted especially in lower extremities (effects
proportionately. Too little protein can of uremia, electrolyte and acid-base
result in malnutrition. Note: Patient on imbalances), impairing peripheral
dialysis may not need to be as vigilant sensation and potentiating risk of tissue
with protein intake. injury.
● Encourage adequate calorie intake, especially ● Establish routine exercise program within limits
from carbohydrates in the nondiabetic patient. of individual ability; intersperse adequate rest
○ Spares protein, prevents wasting, and periods with activities.
provides energy. Note: Use of special ○ Aids in maintaining muscle tone and
glucose polymer powders can add joint flexibility. Reduces risks
calories to enhance energy level associated with immobility (including
without extra food or fluid intake. bone demineralization), while
● Discuss drug therapy, including use of calcium preventing fatigue.
supplements and phosphate binders such as ● Address sexual concerns.
aluminum hydroxide antacids (Amphojel, ○ Physiological effects of uremia and
Basalgel) and avoidance of magnesium antacids antihypertensive therapy may impair
(Mylanta, Maalox, Gelusil); vitamin D. sexual desire and performance.
○ Prevents serious complications ● Identify available resources as indicated. Stress
(reducing phosphate absorption from necessity of medical and laboratory follow- up.
the GI tract and supplying calcium to ○ Close monitoring of renal function and
maintain normal serum levels, reducing electrolyte balance is necessary to
risk of bone demineralization or adjust dietary prescription, treatment or
fractures, tetany); however, use of make decisions about possible options
aluminum – containing products should such as dialysis and transplantation.
be monitored because accumulation in ● Identify signs and symptoms requiring
the bones potentiates osteodystrophy. immediate medical evaluation (Low -grade
Magnesium products potentiate risk of fever, chills, changes in characteristics of urine
hypermagnesemia. Note: Supplemental and sputum, tissue swelling and drainage, oral
vitamin D may be required to facilitate ulcerations;
calcium absorption. ○ Depressed immune system, anemia,
● Stress importance of reading all product labels malnutrition all contribute to increased
(drugs and food) and not taking medications risk of infection.
without prior approval of healthcare provider. ● Numbness and tingling of digits, abdominal and
○ It is difficult to maintain electrolyte muscle cramps, carpopedal spasms; Uremia and
balance when exogenous intake is not decreased absorption of calcium may lead to
factored into dietary restrictions, peripheral neuropathies.
(hypercalcemia can result from routine ● Joint swelling and tenderness, decreased ROM,
supplement use in combination with reduced muscle strength;
increased dietary intake of calcium – ○ Hyperphosphatemia with corresponding
fortified foods and medications calcium shifts from the bone may result
containing calcium). in deposition of the excess calcium
● Review measures to prevent bleeding and phosphate as calcifications in joints and
hemorrhage, (use of soft toothbrush, electric soft tissues. Symptoms of skeletal
razor); avoidance of constipation, forceful involvement are often noted before
blowing of nose, strenuous exercise and contact impairment in organ function is
sports. evident.
○ Reduces risks related to alteration of ● Headaches, blurred vision, periorbital and sacral
clotting factors and decreased platelet edema, “red eyes”;
count. ○ Suggestive of development and poor
● Instruct in self – observation and self-monitoring control of hypertension, or changes in
of BP, including scheduling rest period before eyes caused by calcium.
taking BP, using same arm or position. ● Review strategies to prevent constipation,
○ Incidence of hypertension is increased including stool softeners (Colace) and bulk
in CRF, often requiring management laxatives (Metamucil) but avoiding magnesium
with antihypertensive drugs, products (milk of magnesia).
necessitating close observation of ○ Reduced fluid intake, changes in
treatment effects (vascular response to dietary pattern, and use of phosphate –
medication). binding products often result in
● Caution against exposure to external temperature constipation that is not responsive to
extremes (heating pad or snow). nonmedical interventions.Use of

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

products containing magnesium ○ To determine fluid retention

increases risk of hypermagnesemia. ● Measure abdominal girth for changes.
○ May indicate increase in fluid retention
● Evaluate mentation for confusion and
Renal disorder impairs glomerular filtration that resulted personality changes.
to fluid overload. With fluid volume excess, hydrostatic ○ May indicate cerebral edema.
pressure is higher than the usual pushing excess fluids ● Observe skin mucous membrane.
into the interstitial spaces. Since fluids are not reabsorbed ○ To evaluate degree of fluid excess.
at the venous end, fluid volume overloads the ● Change position of client timely.
lymphLinks to an external site. system and stays in the ○ To prevent pressure ulcers.
interstitial spaces leading the patient to have edema, ● Review lab data like BUN, Creatinine, Serum
weight gain, pulmonary congestion and HPN at the same electrolyte.
time due to decrease GFR, nephron hypertrophied leading ○ To monitor fluid and electrolyte
to decrease ability of the kidney to concentrate urine and imbalances
impaired excretion of fluid thus leading to ● Restrict sodium and fluid intake if indicated
oliguria/anuria. ○ To lessen fluid retention and overload.
Excess Fluid Volume ● Record I&O accurately and calculate fluid
Assessment volume balance
● Patient may manifest: ○ To monitor kidney function and fluid
● Edema retention.
● Hypertension ● Weigh client
● Weight gain ○ Weight gain indicates fluid retention or
● Pulmonary congestion (SOB, DOB) edema.
● Oliguria ● Encourage quiet, restful atmosphere.
● Distended jugular vein ○ To conserve energy and lower tissue
● Changes in mental status oxygen demand.
Diagnosis ● Promote overall health measure.
● Fluid Volume Excess R/T decrease glomerular ○ To promote wellness.
filtration rate and sodium retention
Planning
Patient will demonstrate behaviors to monitor fluid status Acute Pain: Pain is a discomfort that is caused by the
and reduce recurrence of fluid excess stimulation of the nerve endings. Any trauma that the
Patient will manifest stabilize fluid volume AEB balance kidney experience (by any causes or factors) perceive by
I&O, normal VS, stable weight, and free from signs of the body as a threat, the body releases cytokine and
edema. prostaglandin causing pain which is felt by the patient at
Nursing Interventions his flank area.
● Establish rapport Assessment
○ To gain patient’s trust and cooperation. ● Patient may manifest:
● Monitor and record vital signs ● Facial Grimaces
○ To assess precipitating and causative ● Guarding behaviors
factors. ● Costovertebral pain/ Flank pain
● Assess possible risk factors ● Limited ROM
○ To obtain baseline data ● Body weakness
● Monitor and record vital signs. ● Facial Mask
○ To obtain baseline data ● Narrowed Focus
● Assess patient’s appetite ● Sleep Disturbance
○ To note for presence of nausea and ● Diaphoresis
vomiting ● RR & BP changes
● Note amount/rate of fluid intake from all sources Planning
● Patient will demonstrate use of relaxation skills
○ To prevent fluid overload and monitor to relieve pain.
intake and output ● Patient will report relief/control of pain.
● Compare current weight gain with admission or Nursing Interventions
previous stated weight ● Establish rapport.
○ To monitor fluid retention and evaluate ○ To get the cooperation of the patient
degree of excess and SO.
● Auscultate breath sounds ● Monitor and record vital signs.
○ For presence of crackles or congestion ○
● Record occurrence of dyspnea ■ To obtain baseline data.
○ To evaluate degree of excess ● Assess pt’s general condition To obtain
● Note presence of edema. baseline data

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

● Accept patient’s description of pain. relaxation technique that helps decrease level of
○ Pain is a subjective experience and pain.
cannot be felt by other. ● Encourage diversional activities such as TV and
● Perform a comprehensive assessment of pain socialization with others.
(location, onset, characteristics, and frequency) ○ Provides diversionary activities that
○ To be able to compare changes from help block the perception of pain by the
previous reports to rule out worsening brain.
of underlying condition/developing ● Assist with self-care activities.
complications ○ To able to perform ADL’s and maintain
● Determine possible pathophysiology and causes good hygiene.
of pain ● Assist in treatment of underlying disease process
○ To know underlying condition that causing pain. Evaluate effectiveness of
leads to pain and possible management therapies.
that would not further aggravate pain. ● Provide for individualized physical therapy/
● Assess patient’s perception along with exercise program that can be continued by the
behavioral and physiological responses. client discharge refer to physical therapist.
○ To know clients attitude towards pain ○ To continue therapeutic effect and
and use of specific pain and wellness for the patient
medication. ● Administer analgesics as ordered.
● Perform pain assessment each time pain occurs, ○ Pharmacologic mgmt for pain
note and investigate changes from previous
report.
○ To rule out worsening of underlying Ineffective Tissue Perfusion: For optimal cell
condition / development of functioning the kidney excrete potentially harmful
complication. nitrogenous product-Urea, Creatinine, Uric Acid but
● Assess patient’s description of pain. because of the loss of kidney excretory functions there is
○ To acknowledge the pain experience impaired excretion of nitrogenous waste product causing
convey acceptance of client’s response in increase in Laboratory result of BUN, Creatinine, Uric
to pain. Acid Level.
● Observe nonverbal cues including how client Assessment
walks, holds body, sits, facial expressions, cool ● Increase in Lab results (BUN, Creatinine, Uric
fingertips/ toes, which can mean constricted Acid Level)
vessels ● Oliguria
○ Observation may/ may not be ● Anuria
congruent with verbal reports indicating ● Edema
need for further evaluation. ● Pulmonary Congestion
● Assess for referral pain as appropriate ● Hypertension
○ To help determine possibility of ● Hematuria
underlying condition or organ Diagnosis
dysfunction requiring treatment. Altered Renal Perfusion RT Glomerular Malfunction
● Review patient’s previous experiences with pain Planning
and methods found either helpful or unhelpful ● Patient will demonstrate participation in his/her
for pain control in the past. recommended treatment program.
○ To rule out worsening of pain due to ● Patient will demonstrate behavior/lifestyle
methods used. changes to prevent complications
● Explore method for alleviation/ control of pain. Nursing Interventions
○ Timely intervention is more likely to be ● Establish rapport
successful in alleviating pain. ○ To get the cooperation of the patient
● Encourage verbalization of feelings about the and SO.
pain. ● Monitor and record vital signs.
○ To allow out let for emotions and ○ To obtain baseline data
enhance coping mechanism. ● Assess patient’s general condition.
● Provide quite environment, calm activities and ○ To obtain baseline data.
adequate rest reinforce ● Determine factors related to individual situation
○ To prevent fatigue and lessen stimuli. and note situation that can affect all body
● Provide comfort measures such as back rub, system.
change position, use of heat/ cold. ○ To assess causative and contributing
○ To provide non-pharmacologic pain factors
management. ● Note characteristic of urine: measure urine
● Instruct/encourage use of relaxation exercise specific gravity.
such as focused breathing. This is a form of ○ To assess for hematuria and proteinuria

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

and renal impairment. recovery. It is used to treat the client’s disease

● Ascertain usual voiding pattern condition.
○ To compare with current situation. ● Promote overall health measure.
● Note presence, location intensity duration of ○ To promote wellness.
pain.
○ May indicate pain on affected organ
● Note mentation status and review lab result such Impaired Urinary Elimination: Renal Failure is a
as BUN and creatinine levels. increase problem which results to loss of kidney functions and as
○ BUN and creatinine levels may alter GFR decrease, the kidney cannot excrete nitrogenous
mentation product and fluid causing impaired in Urinary elimination
● Monitor BP, ascertain patient’s usual range. and together with prolonged use of medications such as
○ GFR may increase rennin and raise BP. NSAIDs this will lead to further kidney destruction which
● Observe for dependent generalized edema. may thus decreasing the glomerular filtration and
○ To note degree of impairment of renal destroying of the remaining nephrons. This will result in
function. to inability of the kidney to concentrate urine which
● Measure urine output on a regular schedule and makes the patient to have a nursing diagnosis of impaired
weigh daily. urinary elimination.
○ To assess renal perfusion and function. Assessment
● Provide diet restriction as indicated, while Patient may manifest:
providing adequate calories. ● Increase in Lab results (BUN, Creatinine, Uric
○ Calories to meet body’s need while Acid Level)
restriction of protein helps limit BUN. ● Oliguria
● Encourage discussion of feelings regarding ● Anuria
prognosis or long term effects of discussion. ● Hesitancy
○ To decrease anxiety about condition ● Urinary Retention
and correct his wrong ideas about Diagnosis
condition. Impaired Urinary Elimination R/T failing glomerular
● Identify necessary changes in lifestyle and assist filtration AEB Impaired excretion of nitrogenous
client to incorporate disease management to products secondary to Renal Failure
ADLs. Planning
○ To promote wellness and prevent ● Patient will verbalize understanding of condition
further progression of complication. ● Patient will participate in measures to
● Assess patient emotional/psychological factors correct/compensate for defects
affecting the current situation. Nursing Interventions
○ Stress or depression may be increasing ● Establish rapport.
the effect of an illness or depression ○ To get the cooperation of the patient
might be the result of being forced into and SO.
inactivity. ● Monitor and record vital signs.
● Establish realistic activity goal with patient. ○ To obtain baseline data.
○ Enhance commitments to promoting ● Assess pt’s general condition
optical outcomes. ○ To know what problem and
● Give information about positive signs of interventions should be prioritize.
improvement such as improve vital signs/ ● Review for laboratory test for changes in renal
circulation. function.
○ To provide encouragement. ○ To assess for contributing or causative
● Provide physiologic support. Maintain calm factors.
attitude but admit concerns if questioned by the ● Establish realistic activity goal with client.
client/SO. ○ Enhance commitments to promoting
○ Honestly can be reassuring when so optimal outcomes.
much activity or worries are apparent to ● Determine clients pattern of elimination
the client or SO. ○ To assess degree of interference.
● Review expectations of the patient/SO. ● Palpate bladder
○ To establish individual goals. ○ To assess retention
● Give patient information that provides evidence ● Investigate pain, noting location
of daily/weekly progress. ○ To investigate extent of interference
○ To sustain motivation. ● Determine client’s usual daily fluid intake
● Encourage patient to maintain positive attitude; ○ To help determine level of hydration.
suggest use of relaxation technique such as ● Note condition of skin and mucous membranes,
guided imagery as appropriate. color of urine.
○ To enhance sense of well being. ○ To assess level of hydration.
● Administer medication as ordered. For faster ● Observe for signs of infection

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

○ To help in treating urinary alterations ○ To prevent further increase in sodium

● Encourage to verbalize fear/concerns level.
○ Open expression allows client to deal ● Promote relaxing environment.
with feelings and begin problem ○ To enhance intake.
solving. ● Provide oral care.
● Emphasize the need to adhere with prescribe diet ○ To prevent further spread of
○ To prevent aggravation of disease dental caries.
condition. ● Provide safety.
● Emphasize importance of having good hygiene. ○ To prevent injury.
○ To promote wellness. ● Maintain bed rest.
● Emphasize importance of adhering to treatment ○ To decrease metabolic demand.
regimen ● Change position every 2 hours.
○ To promote wellness ○ To prevent ulcerations.
● Position the bed into semi-fowler’s position.
○ To enhance lung expansion.
Imbalanced Nutrition: Less Than Body Requirements: ● Limit fluid intake as ordered.
Due restricted foods and prescribed dietary regimen, an ○ To prevent water retention.
individual experiencing renal problem cannot maintain ● Encourage to do
ideal body weight and sufficient nutrition. At the same ○ Passive range of motion exercise. To
time patients may experience anemia due to decrease have proper circulation of blood.
erythropoietic factor that cause decrease in production of ● Encourage early ambulation.
RBC causing anemia and fatigue ○ To prevent muscle atrophy.
Assessment ● Regulate Intravenous line as Ordered.
● Anorexia ○ To maintain hydration status.
● Anemia ● Administer Medications as ordered.
● Fatigue ○ To prompt treatment.
● Reported inadequate food intake less than
recommended daily allowance
Diagnosis Activity Intolerance
● Altered Nutrition: Less than body Requirements May be related to
R/T Catabolic State, Anorexia and Malnutrition ● Generalized weakness
secondary to Renal Failure Possibly evidenced by
Planning ● Reports of fatigue on exertion
● Patient will display normalization of laboratory ● Lack of energy
values and be free of signs of malnutrition. Desired Outcomes
● Patient will demonstrate behaviors, lifestyle Child will attain increased tolerance for activity.
change to regain and maintain an appropriate Nursing interventions
weight. ● Assess the extent of weakness, fatigue,
Nursing interventions ● ability to participate in active and passive
● Establish rapport activities. Provides information about the
○ To gain patient’s trust. impact of activities on fatigue and energy
● Assess general appearance and monitor vital reserves.
signs. ● Encourage quiet play, reading, watching tv,
○ To establish baseline data. games during times of fatigue. Provides
● Identify patient at risk for malnutrition. relaxation, stimulation and requires minimal
○ To assess contributing factors. energy expenditure.
● Ascertain understanding of individual nutritional ● Schedule care and provide rest periods following
needs. an activity; allow the child to set own limits in
○ To determine what information to the amount of exertion tolerated. Promotes
provide the patient. autonomy and control of situations as the
● Assess weight, age, body build, strength, rest presence of a chronic disease may encourage
level. independence.
○ To provide comparative baseline. ● Explain to child purpose for restrictions; explain
● Assist in developing individualized regimen. when to rest and when to stop an activity to the
○ To control underlying factors. child. Promotes understanding of the need to
● Provide diet modification as indicated. conserve energy and rest.
○ To establish a nutritional plans. ● Educate parents and child that complete
● Determine whether patient prefers more calories participation in activities is essential and should
in a meal. be sustained for as long as possible (within
○ To establish a nutritional plans. capabilities and disease restriction). Promotes an
● Avoid high in sodium-rich food. active and normal life for the child with a

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

chronic illness. Desired Outcomes

● Parents and child will identify positive coping
mechanisms.
Disturbed Body Image ● Parents and child will begin to work through the
May be related to grief process.
● Biophysical and psychosocial factors Nurisng interventions
Possibly evidenced by ● Assess stage of grieving process, difficulties
● Verbal and nonverbal responses to change in encountered, sentiments concerning long-term
body appearance, disruptions in school illness and potential loss of the child.
attendance and engagement in school activities ○ Provides knowledge about the stage of
and socialization grieving as duration to work through
● Negative feelings about own body, multiple the process differs with individuals; the
stressors, and change in daily livin longer the illness, the greater the
● Severe growth retardation (in height and parents and significant others will be
weight); dry skin, facial puffiness able to progress towards acceptance.
Desired Outcomes ● Encourage parent and child to express feelings
● Client will verbalize positive feelings about self. and concerns about the current situation.
Nursing Interventions ○ Allows for feedbacks essential to work
● Assess child for feelings about skills, long-term through grieving.
illness, struggle in school and social situations, ● Provide emotional and spiritual support in an
short stature, inability to keep up with peers. accepting environment and refrain from
○ Provides information about the state of discussions that will provoke guilt or anger.
self-concept and special needs. ○ Provides for the emotional needs of
● Allow expression of feelings and concerns and parents and assists them to adjust with a
assist with open communication to parents, sick child without adding stressors that
teachers, and peers. are hard to resolve.
○ Provides an opportunity to release ● Assist to identify and use effective coping
feelings and decrease ill feelings about methods and to understand situations over which
the change in appearance. they have no control.
● Give importance to positive activities and ○ Promotes the use of coping
achievements, refrain from any negative mechanisms over a lengthy period of
judgments. time of physical and emotional stress
○ Promotes positive body image, on significant others which may be
confidence, self-esteem. positive or negative.
● Support parents to be adaptive in the care of the ● Teach parents of stages of grieving and
child and to consolidate care and routines into behaviors that are common in resolving grief.
family routines. ○ Promotes understanding of feelings and
○ Promotes the well-being of the child behaviors that are exhibited by grief.
and a sense of belonging. ● Assist parents and child to develop coping skills,
● Educate parents to maintain support for the problem-solving skills, and approaches that may
child. be used.
○ Encourages acceptance of the child ○ Promotes coping ability over a
with special needs (dialysis, dietary prolonged period of illness and assists
needs, urinary device, medications). in the resolution of family stress.
● Educate child and parents about dietary ● Refer to a social worker and/or counseling as
selections which can be tolerated while dining indicated.
with peers. ○ Offers information and support to
○ Promotes social interactions with parents and family in need of
friends within limitations imposed by psychologic, economic assistance.
the disease. ● Refer to clergy, local support groups for kidney
diseases.
○ Provides support and assistance in
Anticipatory Grieving adapting and accepting chronic illness
May be related to and services and information for care.
● Perceived potential loss of the child by parents
● Perceived potential loss of physiopsychosocial
well-being by child Risk for Infection
Possibly evidenced by May be related to
● Expression of distress of possible loss, ● Pulmonary edema
impending kidney failure, kidney dialysis, ● Metabolic acidosis
unanticipated death of the child ● Uremia

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 Care of Clients with Problems with Life threatening Conditions, Acutely Ill/Multi-organ Problem, High Acuity & Emergency
Cruz, Larraine Jhasmine D.
BSN-4E2

● Loss of appetite administer diuretics as ordered.

Desired Outcomes ○ Provides an indication of renal function
● Child will not experience infection as evidenced affecting output with water and
by temperature remains <99° F, normal WBC electrolyte retention as the disease
count, urine and/or blood cultures negative. progresses and nephrons are destroyed.
Nursing Interventions ● Assess bone pain and deformities affecting
● Assess temperature, respiratory and urinary ambulation and activities; administer
system changes as the disease progresses. supplemental vitamin D, calcium, and alkalizing
○ Provides information about the agents, as ordered.
presence of infection caused by ○ Provides an indication of
progressive chronic disease and its osteodystrophy caused by a
deteriorating effect on all systems. calcium-phosphorus imbalance
● Assess lab results for infection (elevated WBC resulting in bone demineralization and
and positive blood cultures). growth retardation; kidney disease
○ To prevent and treat an infection. results in the inability to synthesize
● Secure urine or sputum cultures for analysis. vitamin D needed to absorb calcium;
○ Identifies the presence and type of acidosis causes dissolution of alkaline
microorganism responsible for salts of bone, phosphate is increased,
infection and specific sensitivities to and calcium decreased as glomerular
antibiotic therapy. filtration is reduced.
● Perform handwashing, medical or surgical ● Monitor RBC, Hct, Hgb and administer iron and
asepsis during procedures or care as appropriate. transfusion of packed red blood cells, as ordered.
○ Instruct child and parents in ○ Indicates the presence of anemia caused
handwashing technique, proper disposal by the depleted production of
of tissues and used articles. erythropoietin by the declining kidneys
Prevents transmission of pathogens to and inadequate iron intake in a
the child. restricted diet.
● Administer antibiotic therapy as ordered (specify ● Assess the presence of acidosis by pH,
drug, dose, route, and times). bicarbonate losses and administer alkalizing
○ Prevents or treats an infection. agents.
● Teach parents and child to decrease the growth ○ Provides an indication of impending
of microorganisms by bathing daily, wiping metabolic acidosis due to the failure of
from front to back after toileting, and wearing the kidneys to excrete metabolic acids
loose cotton underwear. that are byproducts of metabolism; the
○ Information empowers parents and hydrogen ion is retained and
child to help prevent infection. bicarbonate is lost as the tubules are
● Teach the child to avoid contact with persons unable to reabsorb it.
with upper respiratory infections. ● Instruct parents and child in dietary needs, to
○ Prevents the transmission of infectious decrease sodium, potassium, phosphorous,
agents that may lead to pneumonia. calcium, iron in the diet, to limit protein and
water intake as ordered and amounts allowed;
provide a list of allowed foods and sample
Risk for Injury menus for planning.
May be related to ○ Promotes compliance with dietary
● Renal failure inclusions or restrictions depending on
Desired Outcomes the degree of renal failure.
● Child will not experience injury as evidenced by ● Educate parents on medication administration
BP remains, Hgb and Hct remain > (specify including actions, dosage, frequency, side effects
lower limit), Child denies bone pain or sensory to report.
loss. ○ Guarantees compliance with correct
Nursing Interventions medication administration; long-term
● Assess blood pressure for alterations; administer medications are given for disease to
antihypertensives ordered. avoid complications and uremic
○ Provides data regarding hypertension syndrome.
evident in advanced renal disease. ● Educate parents and child about dialysis
● Assess for sensory loss, confusion neurologic procedure and frequency if appropriate; include
and changes in consciousness. biologic, psychological and social effects.
○ Reveals possible changes in neurologic ○ Supplies information if dialysis is
status as kidney function deteriorates required; usually based on creatinine
and uremic syndrome appears. level which indicated the ability of the
● Assess I&O, electrolyte panel, and creatinine; kidneys to excrete waste materials and

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Cruz, Larraine Jhasmine D.
BSN-4E2

the degree of renal failure.

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