Fluid and Electrolyte Imbalances related to Chronic Kidney Disease (CKD)

Nursing Care Plan for Chronic Kidney Disease / Chronic Renal Failure

Definition

Chronic renal failure is usually the end result of loss of renal function gradually (Doenges, 1999; 626)

Chronic kidney failure occurs when the kidneys are not able to maintain an internal environment that is consistent with the life and recovery of function is not started. In most healthy individuals transition from status to chronic or persistent disease is very slow and wait a few years. (Barbara C. Long, 1996; 368)

Chronic renal failure or end stage renal disease (ESRD) is a progressive renal dysfunction and irreversible where the body's ability to maintain metabolism and failed fluid and electrolyte balance, causing uremia (urea retention and other nitrogen waste in the blood). (Brunner & Suddarth, 2001; 1448)

Chronic renal failure is a progressive development of renal failure and slow, usually lasts several years. (Price, 1992; 812)


Causes 

Causes of CRF according to Price, 1992; 817, divided into eight classes, among others:

1. Infections such as chronic pyelonephritis.
2. Inflammatory diseases such as glomerulonephritis.
3. Hypertensive vascular disease, such as benign nephrosclerosis, malignant nephrosclerosis, renal artery stenosis.
4. Connective tissue disorders such as systemic lupus erythematosus, polyarteritis nodosa, progressive systemic sclerosis
5. Congenital and hereditary disorders such as polycystic kidney disease, renal tubular acidosis.
6. Metabolic diseases such as: diabetes, gout, hyperparathyroidism, amyloidosis.
7. Toxic nephropathy, eg analgesic abuse, lead nephropathy.
8. Obstructive nephropathy, for example:

• Upper urinary tract: calculi neoplasm, fibrosis netroperitoneal.
• Lower urinary tract: prostatic hypertrophy, urethral stricture, congenital anomalies of the neck of the bladder and urethra.

Nursing Diagnosis for Chronic Kidney Disease (CKD) : Fluid and Electrolyte Imbalances related to edema, secondary : the liquid volume is not balanced, and therefore retention of Na and H2O

Goal :
Maintaining an ideal body weight without excess fluid

Outcomes:
no edema,
balance between input and output


Intervention:
1. Assess fluid status by measuring body weight per day, the balance of input and output, skin turgor vital signs

2. Limit fluid intake
R /: fluid restriction will determine ideal body weight, urine output, and response to therapy.

3. Explain to patients and families about the liquid restrictions.
R /: Understanding increase patient cooperation and families in the fluid restriction.

4. Instruct patient / teach the patient to record the use of fluids, especially income and output.
R /: To find out the balance of inputs and outputs.


Nursing Care Plan for Chronic Renal Failure - CRF

Nursing Diagnosis and Nursing Intervention for CRF - Chronic Renal Failure

Assessment and Nursing Diagnosis for UTI

Urinary Tract Infection

Urinary tract infection is the development of microorganisms in the urinary tract, but under normal circumstances does not contain bacteria, viruses, or other microorganisms. Urinary tract infections can occur anywhere, from the urethra, uterus bladder, ureters (fibromuskuler channel that drains urine from the kidney to the urinary contents) or kidney.

Symptoms of Urinary Tract Infection

• Frequent urination along with the feeling of need to urinate even though there may be a little urine to pass.
• Nocturia: Need to urinate at night.
• Urethritis: Discomfort, irritation or pain in meatus or a burning sensation along anyway urethra with urination (dysuria).
• Pain in the midline suprapubic region.
• Pyuria: Pus in urine or urethral discharge.
• Hematuria: Blood in the urine (not always visible to the eye, but often revealed during urine tests).
• Pyrexia: Mild fever
• Cloudy and foul-smelling urine

Nursing Assessment of Urinary Tract Infection

1. Physical examination : do head to toe
2. History or presence of risk factors :

• Is there a history of previous infections ?
• Is there a history of obstruction of the urinary tract ?

3. The presence of factors predisposing patients to nosocomial infections .

• What about mounting folley catheter ?
• Immobilization in a long time ?
• Is urinary incontinence occurs ?

4. Assessment of clinical manifestations of urinary tract infections

• How voiding pattern ? to detect the occurrence of UTI predisposing factors (encouragement, frequency, and amount)
• Is there dysuria ?
• Is there urgency ?
• Is there hesitancy ?
• Is there a pungent smell of urine ?
• How orine output of volume, color ( grayish ) and the concentration of urine ?
• Is there a suprapubic pain - usually on lower urinary tract infection ?
• Are there any pelvic pain or waist - usually the upper urinary tract infection ?
• Increased body temperature is usually in the upper urinary tract infections.

5. Psychological assessment of patients :
How feelings toward patients and treatment outcome measures that have been done ?
Is there any sense of shame or fear of recurrence of the disease.


Nursing Diagnosis of Urinary Tract Infection

1. Impaired sense of comfort: Acute Pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.

2. Altered Urinary Elimination related to mechanical obstruction of the bladder or other urinary tract structures.

3. Deficient Knowledge: about condition, prognosis, and treatment needs related to lack of resources.

Pathophysiology of Herniated Nucleus Pulposus

Herniated intervertebral disc in all directions can occur due to trauma or physical stress. Herniated into the superior or inferior direction, through the cartilage plate into the vertebral body named as "Schmorl nodules" (usually found incidentally on radiological or autopsy picture). Most herniation occurs in the posterolateral direction with respect to the following factors: the nucleus pulposus which tend to be located further away in the posterior and the posterior longitudinal ligament which tends to reinforce the annulus fibrosus in the middle of the posterior. This event is also known by various other names such as rupture of the annulus fibrosus, Herniated Nucleus Pulposus, ruptured disc, pinched nerve and herniated discuc.

At first the nucleus pulposus, herniation occurs through a concentric ring the annulus fibrosus is torn, and causing another rings on the outside of a local stand still intact (Focal). Such a situation is called as Protusio Discus. If the process continues, the material nuclei will then slip out of the disc to the anterior ligament longitudinal posterior (disc herniation free fragment).

Usually protusio extraction posterolateral disc will hit the ipsilateral nerve root at the exit of nerves bag deva (eg disc herniation of L4 - L5 left will clamp the left L5 nerve root). Pinching the nerves will show symptoms and signs in accordance with the distribution redikuler innervation. Significant central disc herniation may involve some element of Cauda Equina on both sides, so that the display radiculopatia bilateral or even sphincter disorders such as urinary retention.

Discus hernia classification depends on the location of the affected is L5, pain that occurs in the sacroiliac joint, hip, lateral thigh and calf, medial leg (pain that radiates down the leg from the pelvis and is called Ishalgia)
Foot drop can lead to weakness and damage done dorsiflexion of the foot and toes or difficulty walking on heels, parastenia occurs in the distal lateral leg and foot middle toe between thumb. Atrophy is not clear, reflexes are usually not real, knee or ankle reflexes may be lost.

Clinical Manifestation of Systemic Lupus Erythematosus (SLE)

Course of the disease Systemic Lupus Erythematosus (SLE) is highly variable. The disease can arise suddenly accompanied by signs exposed to various systems in the body. Can also be chronic with symptoms in a system that gradually followed by symptoms that affected the immune system. In the chronic type there are remissions and exacerbations. Remission may last for years.

Onset of the disease can be spontaneous or preceded by precipitation factors such as sun exposure, viral infections / bacterial remedy. Each attack is usually accompanied by a clear common symptoms such as fever, poor appetite, weakness, weight loss, and irritability. The most prominent is fever, sometimes with chills.



Musculoskeletal symptoms

The most common symptom of SLE is; musculoskeletal symptoms, such as arthritis (93%). The most commonly affected are the proximal interphalangeal joints followed by knee, wrist, metacarpophalangeal, elbow and ankle. Besides swelling and pain may also include joint effusion. Arthritis is usually symmetrical, without causing deformity, contractures or ankylosis. Sometimes there are rheumatoid nodules. Vascular necrosis can occur in various places, and was found in patients receiving treatment with high-dose streroid. The most commonly affected is the femoral head.


Mucocutaneous symptoms

Abnormalities of the skin, hair or mucous membrane was found in 85% of cases of SLE. Skin lesions are most commonly found in SLE is ; skin lesions of acute, subacute, discoid, and reticular livido .
Skin rash butterfly-shaped form rather edamatus erythema on the nose and cheeks. With proper treatment, this disorder can be healed without scarring. On the part of the body exposed to the sun can skin rash that occurs due to hypersensitivity. These lesions include acute skin lesions. Skin lesions typical subacute annular shaped.

Discoid lesions progressed through three stages: erythema, hyperkeratosis and atrophy . Usually presents as erythematous patches of elevated, covered by keratin scales with the blockage of the follicle. If it lasts longer be shaped silikatriks.
Vasculitis can cause ulceration of the skin in the form of small to large. Often also seemed bleeding and periungual erythema. Reticular Livido a mild form of vasculitis, it is often found in SLE.


Kidney

Renal insufficiency was found in 68% of cases of SLE. The most frequent manifestation is proteinuria or hematuria. Hypertension, renal failure nephrotic syndrome is rare, only found in 25% of cases of SLE urine showed abnormalities.
There are 2 kinds of pathological abnormalities in the kidneys, which diffuse lupus nephritis, and membranous lupus nephritis. Lupus nephritis is the most severe disorder. Usually appear clinically as nephrotic syndrome, hypertension and impaired renal function with moderate to severe. Membranous lupus nephritis are less common. Marked with nephrotic syndrome, impaired renal function and mild course of the disease may be rapid or slow but progressive.
Other renal abnormalities that may be found in SLE is chronic pyelonephritis, renal tuberculosis. Kidney failure is one cause of death chronic SLE.


Central Nervous

Disorders of central nervous system consists of two main abnormalities organic psychosis and convulsions.
Organic brain disease is usually found in conjunction with active SLE symptoms in others systems. Patients showing symptoms of hallucinations in addition to the typical symptoms of organic brain as difficult to calculate and could not recall the pictures ever seen.
Steroid psychosis also include organic brain syndrome which is clinically indistinguishable from lupus psychosis. The difference between the two can only be known by lowering or raising the dose of steroids used. Lupus psychosis improved if the steroid dose is increased and vice versa.
Seizures arising grandmal type normally included. Other abnormalities that may be found is aphasia, hemiplegia.


Eye

Eye disorders may include conjunctivitis, sub - conjunctival hemorrhage and the body sitoid in the retina.


Heart

Inflammation of various parts of the heart can occur, such as pericarditis, endocarditis and myocarditis. Chest pain and arrhythmia may occur as a result of these circumstances.


Lungs

Can occur in lupus pleurisy (inflammation of the lining of the lungs) and pleural effusion (accumulation of fluid between the lung and the wrapper). As a result of these events often arise chest pain and shortness of breath.

Gastrointestinal tract

Abdominal pain present in 25 % of cases of SLE , may be accompanied by nausea and diarrhea. Symptoms disappear quickly if systemic disorders receive adequate treatment. Pain that may arise due to the sterile peritonitis or arteritis of small blood vessels that lead to bowel mesentery and intestinal ulceration. Arteritis can also cause pancreatitis.


Hemic - Lymphatic

Lymph nodes are commonly affected are the axillary and cervical, with the characteristics of non-tender and soft. Splenomegaly other lymphoid organs is usually accompanied by an enlarged heart. Lien in the form of myocardial damage or thrombosis associated with lupus anticoagulant. Anemia can be found in the period of disease progression LES, which is mediated by the immune and non-immune.

Decreased Cardiac Output - Ventricular Septal Defect Care Plan

Ventricular Septal Defect

A ventricular septal defect (VSD) is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart.

A ventricular septal defect happens during pregnancy if the wall that forms between the two ventricles does not fully develop, leaving a hole. A ventricular septal defect is one type of congenital heart defect. Congenital means present at birth.

Decreased Cardiac output Definition

Inadequate blood pumped by the heart to meet metabolic demands of the body



Nursing Diagnosis : Decreased cardiac Output related to cardiac malformations.

Goal:

• Decreased cardiac output does not occur

Interventions:

1. Observation quality and strength of heart rate, peripheral pulses, skin color and warmth
2. Enforce the degree of cyanosis (eg, mucous membrane color degrees of finger)
3. Give digitalis medications appropriate order.
4. Give diuretic medications appropriate order.

Rationale:

1. Provide data for the evaluation of interventions and enable early detection of complications.
2. Determine the development of the client's condition and determine appropriate interventions.
3. Digitalis drugs that strengthen the heart muscle contractility increases cardiac output / clients at least able to adapt to the situation.
4. Reduce excess fluid in the body pile so the heart will be lighter.

NANDA Decreased Cardiac Output

Acute Pain - Nursing Care Plan for Hypertensive Heart Disease

Hypertensive Heart Disease

Hypertensive heart disease includes a number of complications of systemic arterial hypertension or high blood pressure that affect the heart.

Symptoms of heart failure include:

• Shortness of breath
• Swelling in the feet, ankles, or abdomen
• Difficulty sleeping flat in bed
• Bloating
• Irregular pulse
• Nausea
• Fatigue
• Greater need to urinate at night

Symptoms of ischemic heart disease may include:

• Chest pain which may radiate (travel) to the arms, back, neck, or jaw
• Chest pain with nausea, sweating, shortness of breath, and dizziness; these associated symptoms may also occur without chest pain
• Irregular pulse
• Fatigue and weakness

Acute Pain Definition

Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of  less than 6 months.



Nursing Care Plan for Hypertensive Heart Disease

Acute Pain (headache) related to increased cerebral vascular pressure.


Goal :

• Client reported pain / discomfort disappeared / controlled .

Interventions and Rationale :

1. Maintain bed rest during the acute phase.

2. Give non-pharmacological measures to eliminate headaches eg, a cold compress on the forehead, back and neck massage, quiet, dim the room lights room lights, relaxation techniques (manual imagination, disktraksi) and leisure time activities.

3. Eliminate / minimize vasoconstriction activity that can increase headache eg, straining during defecation, coughing and bending length.

4. Assist patients in ambulation as needed.

5. Give liquids, soft foods, regular oral care in the event of bleeding nose or nasal pack has been done to stop the bleeding.

Rationale:

1. Minimize stimulation / promote relaxation.

2. Actions that reduce cerebral vascular pressure and the slow / block sympathetic response is effective in relieving headaches and complications.

3. Activities that increase vasoconstriction causing headaches in an increase in cerebral vascular pressure.

4. Dizziness and blurred vision often associated with pain kepala.pasien can also experience episodes of postural hypotension.

5. Increase the general comfort, compress the nose can interfere with swallowing or breathing requires mouth, causing stagnation oral secretions and mucous membranes dry out.

Physical Examination for Congestive Heart Failure (CHF)

Nursing Care Plan for Congestive Heart Failure - CHF