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This is the nonoliguric form of renal failure and occurs predominantly after exposure of the patient to nephrotoxic agents; it may also occur with burns cheap endep 50mg with visa medicine 802, traumatic injury, and the use of halogenated anesthetic agents. The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. Although the volume of urinary output may reach normal or elevated levels, renal function may still be markedly abnormal. Because uremic symptoms may still be present, the need for expert medical and nursing management continues. The patient must be observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to increase. The recovery period signals the improvement of renal function and may take 3 to 12 months. Protein catabolism results in the release of cellular potassium into the body fluids, causing severe hyperkalemia (high serum potassium levels). Treatment • Dialysis • Transplantation • Nursing diagnosis –Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water –Imbalanced nutrition: less than body requirements related to anorexia, nausea and vomiting, dietary restrictions, and altered oral mucous membranes Nursing diagnosis –Deficient knowledge regarding condition and treatment regimen –Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure –Risk for situational low self-esteem related to dependency, role changes, changes in body image, and sexual dysfunction Chronic Renal Failure • Nursing care: see nursing process below Dialysis • Dialysis is used to remove fluid and uremic waste products from the body when the kidneys are unable to do so. Skin turgor and presence changes and evaluating Maintains dietary of edema interventions. Blood pressure, pulse determined on basis of Exhibits normal rate, and rhythm weight, urine output, skin turgor without f. Medications and fluids cooperation with fluid difficulty breathing used to take or administer restriction. Increasing patient comfort breath intravenous promotes compliance Performs oral b. Nursing Diagnosis: Imbalanced nutrition; less than body requirements related to anorexia, nausea, vomiting, dietary restrictions, and altered oral mucous membranes Goal: Maintenance of adequate nutritional intake 1. Past and present dietary restrictions that are levels) patterns are considered appealing 2. Assess for factors contributing to dietary intake is words rationale for altered nutritional intake: provided. Encourage high-calorie, low- produce anorexia and increases or protein, low-sodium, and low- feeling of fullness. Alter schedule of medications so relationships between without edema; that they are not given diet and urea and wound healing and immediately before meals. Lists provide a positive kidney disease and increased approach to dietary urea and creatinine levels. Provide written lists of foods reference for patient and allowed and suggestions for family to use when at improving their taste without use home. Decreased serum decreased albumin and albumin levels other proteins, edema formation, and delay in wound healing. Nursing Diagnosis: Deficient knowledge regarding condition and treatment Goal: Increased knowledge about condition and related treatment 1. Provides baseline for Verbalizes renal failure, consequences of further explanations and relationship of renal failure, and its treatment: teaching. Understanding of renal becomes ready to dietary restrictions function understand and accept as they relate to d. Rationale for treatment or her life does not have States in own (hemodialysis, peritoneal to revolve around the words relationship dialysis, transplantation) disease. Assist patient to identify ways to Verbalizes plans to incorporate changes related to continue as normal illness and its treatment into a life as possible lifestyle. Provide oral and written information and information as appropriate instructions to about: clarify questions a. Treatment options Nursing Diagnosis: Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure Goal: Participation in activity within tolerance 1. Indicates factors Participates in activity intolerance: contributing to severity increasing levels of a. Retention of waste exercise within limits Alternates rest and products and adequate rest. Promote independence in self- encouraged after selected self-care care activities as tolerated; assist dialysis treatments, activities if fatigued. Nursing Diagnosis: Risk for situational low self-esteem related to dependency, role changes, change in body image, and change in sexual function Goal: Improved self-esteem 188 1. Provides data about Identifies responses and reactions to illness problems encountered previously used and treatment.

There appear to be undertones of frustration and distrust in mental health professionals in the following extracts generic 10 mg endep with mastercard symptoms 9dp5dt, in which Diana and Steve talk about their prescribers’ failure to tailor medication to their circumstances: Diana, 11/02/2009 D: They might put my medication up or might have brought it down but didn’t apply to the way I was at the time. D: No, no, just, just to get along alright, but um, a couple of things weren’t going right but that didn’t matter. Steve, 04/02/2009 L: Um, what’s been the problem with previous um, doctors and that? S: Basically you go and tell them what’s happening and they just didn’t really care. It’s just like, see ya later, like they won’t give you anything for you, it’s just like see you later. Diana indicates that changes in her medication regimen in the past did not reflect fluctuations in her personal circumstances (“They might put my medication up or might have brought it down but didn’t apply to the way I was at the time. She elaborates that prescribers did not take into account difficulties she was experiencing, which were possibly medication- related (“a couple of things weren’t going right but that didn’t matter”) and 233 implies that they failed to take any action because she remained adherent (“just as long as she takes her medication”). Steve indicates that despite informing his prescriber of his circumstances, these were dismissed and his regimen was not tailored to his needs (“you go and tell them what’s happening and they just didn’t really care…like they won’t give you anything for you”). Steve and Diana position prescribers whose practice does not reflect consideration of their needs as lacking genuine concern for consumers’ well-being (“They’re only covering their backs”, “another, like $100 you know, sign this so they can get paid”). Although neither Steve nor Diana associated their prescribers’ failure to tailor medication to non- adherence in the above extracts, they both reported at other points in their interviews that they became non-adherent due to experiencing side effects which were not addressed by prescribers. In the following extracts, Cassie and Oliver negatively evaluate their past experiences of prescribers failing to tailor their medication regimen to their schedules: Cassie, 04/02/2009 L: So they didn’t tell you. Do you find I mean I know you think your relationship with Dr A’s pretty good now, and you’ve mentioned in the past that you’ve had some not so great relationships with health workers, psychiatrists and that. Um, some of them aren’t um, but I remember like, um, why can’t you have time off to come and get your injection, like 2 hours off to get the injection? And uh, why can’t you have um time off to come and see um, see the psychiatrist when you’re working? L: So he didn’t seem concerned about- O: No, I tried to explain to him I’m working, I’m fine at the moment and it’s like, two days won’t hurt. Cassie directly positions some of her past prescribers as “out of touch with reality”. Cassie and Oliver report that their prescriber and social worker, respectively, failed to take into account their work commitments when arranging medication appointments. They both indicate that past prescribers have held unrealistic expectations that they should be able to prioritise medication appointments over employment commitments and that prescribers were inflexible in organizing more suitable times. Whilst they do not link prescribers’ rigidity and failure to consider other commitments 235 directly to non-adherence, it could be argued that if appointments consistently interfere with other life commitments, some consumers may be more likely to become non-adherent. Thus, it may be important for prescribers to tailor the medication schedule around consumers’ other commitments, such as employment, in addition to tailoring it to symptom fluctuations and situational stressors. Whereas previous extracts have emphasized the importance of tailoring medication regimens to consumers’ situations, the following extracts highlight the importance of prescribers tailoring treatment information to their level of understanding or intelligence: Brodie, 21/08/2008 L: How do you think health workers could assist in I guess, well encouraging or helping people to take their medication? I’d like to think I’ve got some brains, but some people, they’re not educated or anything, so it’s probably harder for them. So yeah, but I think the health workers should individually, just um, get to know their patients a bit more than what they should I think. That’s why me and Dr A get along well now, because, I just said to her, look I know I’ve got this thing that lots of other people have but I don’t want to be talked down to like I’m stupid or anything. Amy, 10/02/2009 236 A: One of my mental health nurses, uh, she was looking after me and was really good at explaining, like from, because I’ve done biology in year 12 and I’m sort of, I used to do a mental health course at Tafe, non-clinical, um, he explained how the medication breaks do? And sort of like, the biological, medical properties of it…Um, because he knew I was intelligent enough, um, that really helped and encouraged me to take it more, because I had more thorough awareness. When asked directly about how health workers could assist with adherence, above, Brodie responds “not to patronize people”, as has been his experience in the past. He elaborates that prescribers should “individually, just um, get to know their patients a bit more” and thus target information accordingly. He implies that the therapeutic alliance with his prescriber improved following a conversation in which he told her to communicate with him as an equal (“I’ve got some brains…I don’t want to be talked down to like I’m stupid or anything”). In line with this, Amy recalls how a mental health worker assisted with her adherence (“that really helped and encouraged me to take it more”), by acknowledging her intelligence and pre- existing knowledge (“because he knew I was intelligent enough”) and, thus, explaining the mechanism of medication to her in appropriate terms.

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