Hypertensive Nephropathy

Renal Nursing

2014

Bryan C. Robles, RN
Master of Science in Nursing Adult Health Nursing University of the East Ramon Magsaysay Memorial Medical Center, Inc.

Belinda Capistrano, RN, MAN Professor

Table of Contents
Microscopic Anatomy and Physiology................................................................................... 02 Assessment Techniques ........................................................................................................... 03 History ............................................................................................................................. 03 Physical Assessment ........................................................................................................ 04 Phsychosocial .................................................................................................................. 05 Diagnostic Assessment .................................................................................................... 05 Pathophysiology ....................................................................................................................... 08 Laboratory and Diagnostic Test ............................................................................................ 11 Nursing Theory ........................................................................................................................ 14 Jean Watsons Philosophy and Science of Caring (Human Caring Science) ....................................................................................... 14 Faye Glen Abdellahs 21 Nursing Problems ................................................................... 17 Nursing Diagnoses ................................................................................................................... 18 Nursing Interventions ............................................................................................................. 19 Complication ............................................................................................................................ 20 Prognosis .................................................................................................................................. 20 References................................................................................................................................. 22 Appendices ............................................................................................................................... 23
Images and Flow Chart Health Promotion Program Concept Map

Hypertensive Nephropathy2014 [email protected] | 1

HYPERTENSIVE NEPHROPATHY Some authors consider it as degenerative disorder that change renal functions often occur with multisystem disorder. Many of these degenerative disorders result from changes in kidney blood vessels. Hypertensive Nephropathy sometimes called as Hypertensive Nephrosclerosis is a problem of thickening in the nephron blood vessels, resulting in narrowing of the vessel lumen. This change decreases renal blood flow and kidney tissue is chronically hypoxic. Ischemia and fibrosis develop over time. Nephrosclerosis occurs with all types of hypertension, atherosclerosis, and diabetes mellitus. The more severe the hypertension, the greater the risk for severe kidney damage. Neprhosclerosis is rarely seen when blood pressure is consistently below 160/110 mm Hg. The changes caused by hypertension may be reversible or progress to Chronic Kidney Disease with months or years.

MICROSCOPIC ANATOMY AND PHYSIOLOGY The nephron is the working unit of the kidney, and it is here that urine is actually formed from blood. There about 1 million nephrons per kidney and each nephron separately make urine from blood. There are two types of nephrons: cortical nephrons and juxtamedullary neprhons. The cortical neprhons are short, with all parts located in the renal cortex. The juxtamedullary nephrons (about 20% of all neprhons) are longer, and their tubes and blood vessels dip deeply into the medulla. The purpose of the juxtamedullary neprhons is to concentrate urine during times of low fluid intake. The ability to concentrate urine allows for continued excretion of wastes with less fluid loss. Blood supply to the nephron is delivered via the afferent arteriole, the smallest, most distal portion of the renal arterial system. From the afferent arteriole, blood flows into the glomerulus, a series of specialized capillary loops. It is through these capillaries that water and small particles are filtered from the blood to make urine. The remaining blood leaves the glomerulus via the efferent arteriole. From the efferent arteriole, blood exits into one of two additional capillary systems: The peritubular capillaries around the tubular part of the cortical nephrons. The vasa recta around the tubular part of juxtamedullary nephrons. Each nephron is a tube like structure with distinct parts. The tube begins with bowmans capsule, a saclike structure that surrounds the glomerulus. The tubular tissue of Bowmans capsule narrows into the proximal convoluted tubule (PCT). The PCT twists and turns, finally
Hypertensive Nephropathy2014 [email protected] | 2

straightening into the descending limb of the loop of Henle. The descending loop of Henle dips in the direction of the medulla but forms a hairpin loop and comes back up into the cortex. There are two segments of ascending limb of the loop of Henle: the thin and thick segments. The distal convoluted tubule (DCT) forms from the thick segment of the ascending limb of the loop of Henle. The DCT ends in one of many collecting ducts located in the kidney tissue. The urine in the collecting duct passes through the papillae and empties into the renal pelvis. Special cells in the afferent arteriole, efferent arteriole, and DCT are known as the juxtamedullary complex. These specialized cells are rennin-producing cells which produce and store rennin. Renin is a hormone that helps to regulate blood flow, glomerular filtration rate (GFR), and blood pressure. Renin is secreted when sensing cells in the DCT (called the macula densa) sense changes in the blood volume and pressure. The macula densa lies next to the reninproducing cells. Renin is produced when the macula densa cells sense that blood volume , blood pressure, or blood sodium levels are low. Renin then converts renin substrate (angiotensinogen) into angiotensin I. This leads to a series of reactions that cause secretion of the hormone the hormone aldosterone. Aldosterone increases kidney reabsorption of sodium and water, restoring blood pressure, blood volume and sodium levels. The glomerular capillary wall has three layers the endothelium, basement membrane and epithelium. The endothelial and epithelial cells lining these capillaries are separated by pores that filter water and small particles from the blood into Bowmans capsule. This fluid is called the filtrate (also ultrafiltrate), or early urine.

ASSESSMENT TECHNIQUES History Family History and Genetic Risk. The family history of the client with a suspected kidney or urologic problem is important because some disorders have familial inheritance pattern. Ask the client whether his or her siblings, parents, parents siblings or grandparents have had renal disease. Demographic Data and Personal History. Age, gender, race and ethnicity are important to assess in the client with any renal or urinary problem. A sudden onset of hypertension in clients older than 50 years of age suggests possible kidney disease. Anatomic gender differences make some disorders worse or more common. Ask client about any previous renal or urologic problems, including tumors, infections, stones, or urologic surgery. A history of any chronic health problems, such as diabetes mellitus or hypertension increases the risk for development of
Hypertensive Nephropathy2014 [email protected] | 3

renal disease. Identify all the clients prescription drugs. Ask the client about the duration of drug use and whether there have been any recent changes in prescribed drugs. Explore the use of over the counter drugs or agents, including vitamin and mineral supplements and replacements, laxatives, analgesics, and nonsteroidal anti-inflammatory drugs. Diet History. Ask the client with known or suspected renal or urologic disorders about his or her diet and any recent changes in the diet. Note any excessive intake or omission of certain food categories. Ask about food and fluid intake. If the client has followed a diet for weight reduction, the details of the diet plan are important. A high-protein intake can result to temporary renal problems. Ask about any change in appetite or in the ability to discriminate tastes. These symptoms can occur with the accumulation of nitrogenous waste products from renal failure. Socioeconomic History. The clients socioeconomic status may influence health care practices. People with limited income or no health insurance often ignore physical problems or delay seeking health care because they lack the funds to pay for tests or treatment. They may find also difficulty following medical advice, having prescription filled, and keeping follow-up appointments. The client health beliefs affect the approach to health and illness. Cultural background or religious affiliation may influence the belief system. Current Health Problem. Encourage the client to describe all health concerns, because some renal disorders cause systemic problems or problems in other body system. Physical Assessment Inspection. Inspect the abdomen and the flank regions with the client in both the supine and the sitting position. Observe the client for asymmetry or discoloration in the flank region, especially in the area of the costovertebral angle (CVA). The CVA is located between the lower portion of the twelfth rib and the vertebral column. Auscultation. Listen a bruit over each renal artery on the midclavicular line. A bruit is an audible swishing sound produced when the volume of the blood or the diameter of the blood vessel changes. A bruit often occurs with blood flow through a narrowed vessel, as in renal artery stenosis. Palpation. Renal palpation can help locate masses and areas of tenderness in or around the kidney. Lightly palpate the abdomen in all quadrants. Ask about areas of tenderness or discomfort and examine nontender areas first. The outline of the bladder may be seen as high as the umbilicus in clients with severe bladder distension. If tumor or aneurysm is suspected, palpation may harm the client. Because the kidneys are located deep and posterior, palpation is easier in thin clients who have little abdominal musculature. For the palpation of the right kidney, the client assumes supine position while you place one hand under the right flank and the
Hypertensive Nephropathy2014 [email protected] | 4

other hand over abdomen below the lower right part of the rib cage. Use the lower hand to raise the flank and the upper hand to depress the abdomen as the client take s a deep breath. The l;eft kidney is deeper and rarely palpable. A transplanted kidney is readily palpable in either the lower right or left abdominal quadrant. The kidney should feel smooth, firm and non tender. Percussion. A distended bladder sounds dull when percussed. After gently palpating to determine the outline of the distended bladder, begin percussion on the lower abdomen and continue in the direction of the umbilicus until dull sounds are no longer produced. If the client identifies flank pain, or tenderness, percuss the nontender flank first. Have a client assume a sitting, side lying, or supine position, and then form one of your hands into a clenched fist. Place your other hand flat over the CVA of the client. Then quickly deliver a firm thump to your hand over the CVA area. Costovertebral tenderness often occurs with kidney infection or inflammation. Clients with inflammation or infection in the kidney or adjacent structures may describe their pain as severe or as a constant, dull ache. Psychosocial Assessment Concerns about the urologic system may evoke fear, anger, embarrassment, anxiety, guilt or sadness in the client. Childhood learning often includes privacy with regard to urination habits. Urologic disorders may bring up forgotten memories of difficult toilet trsining and bedwetting or of childhood experiences of exploring ones body. The client may ignore symptoms or delay seeking health care because of emotional responses or cultural taboos about the urologenital area. Diagnostic Assessment Blood Test Serum Creatinine A creatinine blood test measures the level of creatinine in the blood. Creatinine is a waste product that forms when creatine breaks down. Creatine is a substance found inmuscle. Creatinine levels help determine how well your kidneys function. Your kidneysare responsible for eliminating creatinine from the body when you urinate. When creatinine levels increase, your kidney function may be impaired. Purpose. Your doctor might order a blood test to assess your creatinine levels if you show signs of kidney disease: fatigue and trouble sleeping, loss of appetite, swelling in the face, wrists, ankles, or abdomen, lower back pain near the kidneys, changes in urine output and frequency, increase in blood pressure. Kidney problems can be related to a number of different diseases or conditions, including decreased blood flow to the kidneys due to dehydration, atherosclerosis, shock,congestive heart failure, or diabetes.

Hypertensive Nephropathy2014 [email protected] | 5

Preparation. Some medications can increase your creatinine levels without causing kidney damage. Let your doctor know if you take: cimetidine, NSAID medications like aspirin or ibuprofen, chemotherapy drugs, cephalosporin. You may be asked to stop taking your medication before the test. Or, your doctor may just note the drug interaction in your files. Other than that, you dont have to do much to preparethe test is just a standard blood draw. Result. Creatinine is measured in milligrams per deciliter of blood (mg/dL). People who are more muscular tend to have higher creatinine levels. Normal creatinine levels range from: 0.7 to 1.3 mg/dL in men and 0.6 to 1.1 mg/dL in women. Increased creatinine levels in the blood are indicators that the kidneys may not be functioning properly. Urine Test Urinalysis A urinalysis is a laboratory test done to detect problems with your body that can appear in your urine. Many illnesses and disorders affect how your body removes waste and toxins. The system that takes care of that is broadly called the excretory system, and includes yourlungs, kidneys, urinary tract, skin, and bladder. Problems with any of these parts of your body can affect the appearance, concentration, and content of your urine. Purpose. Your doctor may order urinalysis if he or she suspects you of having certain conditions, or you experience certain symptoms, including: abdominal pain, back pain, blood in the urine, diabetes, kidney disease, liver disease, painful urination, urinary tract infection. If youve been diagnosed with any of these conditions, your doctor may use urinalysis testing to check on the progress of treatments or tracking the progression of a disease. Preparation. One of the best ways to prepare for giving a urine sample is to make sure you drink enough water to provide an adequate sample. Prior to the test, tell your doctor about any medications or supplements you take as these may affect the results. Result. Test Color

Normal Range Pale yellow

Odor

Specific aromatic odor,

Significance of Abnormal Findings Dark Amber indicates concentrated urine. Very pale yellow indicates dilute urine. Dark red or brown indicates blood in the urine; brown also may indicate increased urinary bilirubin level, red may also indicate presence of myoglobin. Other color changes may result from diet or medications. Fouls smell indicates possible infection,

Hypertensive Nephropathy2014 [email protected] | 6

Turbidity Specific gravity

pH

Glucose Ketones

Protein

Bilirubin RBC

WBC

Casts

Crystals

Bacteria

Parasites

Leukoesterase

dehydration, or ingestion of certain foods or drugs. Clear Cloudy urine indicates infection, sediment, or high levels of urinary protein. 1.000-1.030 Increased in decreased renal perfusion, inappropriate antidiuretic hormone secretion, or congestive heart failure. Decreased in chronic renal insufficiency, diabetis insipidus, malignant hypertension, diuretic administration, and lithium toxicity. Average: 6; possible Changes are caused by diet, the administration of range: 4.6-8 medication, infection, freshness of specimen, acid-base imbalance and altered renal function. <0.5 g/day (<2.78 Presence reflects hyperglycemia or a decrease in mmol/L) the renal threshold for glucose. None Presence reflects incomplete metabolism of fatty acids, as in diabetic ketoacidosis, prolonged fasting, anorexia nervosa. 0.8 mg/dL Increased amounts may indicate stress, infection, recent strenuous exercise, or glomerular disorder. None Presense suggests hepatic or billiary disease or obstruction. 0-2 per high-power field Increased amounts are normal with indwelling or intermittent catheterization or menses but may reflect tumor, stones, trauma, glomerular disorder, cystitis, or bleeding disorders. Male: 0-3 per high-power Increased amounts may indicate infectious or field inflammatory process anywhere in the Female: 0-5 per highrenal/urinary tract, renal transplant rejection, power field fever or exercise. A few or none, composed Increased amounts indicate the presence of bacteria or protein, which is seen in severe renal of RBS or WBC, protein disease and could also indicate urinary calculi. or tubular casts None Presence of normal or abnormal crystals may indicate that the specimen has been allowed to stand. <1000 colonies/mL Increased amounts indicate the need for urine culture to determine the presence of urinary tract infection. None Presence of Trichomonas vaginalis indicates infection, usually of the urethra, prostate or vagina. None Presence suggests urinary tract infection.
Hypertensive Nephropathy2014 [email protected] | 7

similar to ammonia

Nitrites

None

Presence suggests bacteria, usually Escherichia coli.

24-Hour Urine Collection These collections are often used to measure urine levels of creatinine or urea nitrogen, sodium, chloride, calcium, catecholamines, or other components. For a composite urine specimen, all urine within the designated time frame must be collected. If other voided or catheterized specimens must be obtained while the collection is in progress, measure and record the amount collected but not added to the time collection. The urine collection may be needed to be refrigerated or stored on ice to prevent changes in the urine during the collection time. The urine collection must be free from fecal contamination. Menstrual blood and toilet tissue also contaminate the specimen and can invalidate the result. Component Creatinine Normal Range Significance of Abnormal Findings 0.8-2 g/24hr Decreased amounts indicate adeterioration in Male: 1-2 g/24hr or renal function caused by renal disease, shock 14-26 mg/kg/24hr hypovolemia, or any condition affecting Female: 0.6-1.8 g/24hr muscle. or 11-20 mg/kg/24hr Increased amounts occur with infections, exercise, diabetes mellitus, and meat meals. 40-220 mEq/24hr Decreased amount are seen in hemorrhage, shock, hyperaldosteronism, and prerenal acute renal failure. Increased amounts are common with diuretic therapy, excessive salt intake, hypokalemia, and acute tubular necrosis 1-14 mg/dL Increased amounts indicate gloerular disease, nephritic syndrome, diabetic nephropathy, urinary tract malignancies, and irritations.

Sodium

Protein

PATHOPHYSIOLOGY Etiology Two pathophysiologic mechanisms have been proposed for the development of hypertensive nephrosclerosis. One mechanism suggests that glomerular ischemia causes hypertensive nephrosclerosis. This occurs as a consequence of chronic hypertension resulting in narrowing of preglomerular arteries and arterioles, with a consequent reduction in glomerular blood flow.
Hypertensive Nephropathy2014 [email protected] | 8

Second is a genetic link for hypertension and related renal failure is supported by studies demonstrating familial clustering of hypertensive nephrosclerosis in black people and, to some extent, in white people. In the Multiple Risk Factor Intervention Trial (MRFIT), no changes in the reciprocal creatinine slope were observed in white people, but a significant loss in kidney function was observed in black people despite similar levels of BP control. Similarly, secondary analyses from the Modification of Diet in Renal Diseases (MDRD) study demonstrated that at equivalent mean arterial pressures greater than 98 mm Hg, black patients had a reduction in their GFR at a rate of approximately 1 mL/min/y more than white patients. These observations have led to investigations into genetic factors predisposing to renal damage. Pathogenesis High systemic blood pressure is the major stimuli that cause the constriction of the afferent arterioles. This response is considered as protective mechanism to maintain the normal pressure in the glomeruli. Baroreceptors that innervate the smooth muscle wall of the afferent arterioles receive the stimuli and travels through the sympathetic nervous system signaling the midbrain to send stimuli for the smooth muscle of the afferent arterioles to constrict decreasing the transmission of high systemic blood pressure to the glomeruli. On the other hand efferent arterioles will simultaneously dilate while the afferent arterioles are being constricted to maintain the normal glomerular pressure which is 60mm Hg. Consistent and uncontrolled pressure exerted to the blood vessel walls will lead to hyperactivity of the surrounding smooth muscle making it enlarged and further constrict the afferent arterioles, moreover it causes barotrauma and primarily stimulates the smooth muscle cells to secrete cytokines and eosiniphil for minimal inflammatory response and secondarily it will independently extrude extra hyaline matrix such as fibrin, collagen and lipids and will be lodged in the lining of the endothelial cells causing thickening on the intima of the arteriole. This type of lesion is called hyaline arteriosclerosis or other termed it as hyperplastic arteriolitis. It was called as hyaline because of its glassy appearance under microscope. Do not be confused with the hyaline cartilage found in the movable joints. The narrowing of the lumen of the afferent arterioles brought by vasoconstriction and hyaline arteriosclerosis will result to decreased blood supply of the glomeruli, leading to structural atrophy resulting from glomerular ischemia and eventually glomerular hyalinization and glomerular necrosis will occur. As the start of glomerular hyalinization, there will be decreased blood flow to the efferent arteriole that leads to ischemia and furthermore necrosis. Efferent arterioles supply blood to the renal tubules or the nephrons, once it was necrotic it will cause tubular necrosis or nephropathy. If damage will persist and not be controlled it will result to Chronic Renal Insufficiency. It will be headed off and eventually develop to Chronic Renal Disease. Morphologic Changes Fibrinoid necrosis of arterioles. This appearance as an eosinophilic granular change in the blood vessel wall, which stains positively for fibrin by histochemical or immunofluorescence
Hypertensive Nephropathy2014 [email protected] | 9

techniques. This change represents an acute event, and it may be accompanied by limited inflammatory infiltrate within the wall. However, usually this pattern of necrosis is not accompanied by prominent inflammation. In the interlobular arterioles, there is intimal thickening caused by proliferation of elongated concentrically arranged smooth muscle cells, together with fine concentric layering of collagen and accumulation of pale staining material likely accumulation of proteoglycans and plasma proteins. This alteration has been referred to as onion-skinning because of its concentric appearance. The lesion also called hyperplastic arteriolitis, correlates well with renal failure in malignant hypertension. Sometimes the glomeruli become necrotic and infiltrated with neutrophils, and the glomerular capillaries may thrombose. The arteriolar and arterial lesions result in considerable narrowing of all vascular lumens, with ischemic atrophy and, at times, infarction distal to the abnormal vessels. Clinical Significance As the pathogenesis continues there will be impending glomerular ischemia and necrosis that will now alter the main function of the kidney which is filtration of the blood to form urine. Large particles from the plasma and protein contents will leak on the glomeruli. Primarily the patient will experience change in urine color and it varies from dark orange, tea-color or even red, this phenomenon is called hematuria. As the disease progresses the patient will observe that there will be bubbles in the urine that indicates proteinuria and later on may result to hypoproteinemia or hypoalbuminemia. Protein in the urine will decrease osmotic pressure specifically the oncotic pressure that will let the fluid accumulated in the interstitial space, in early stage edema will be manifested in the eyes, face and ankles but later on patient will experience anasarca extreme generalized edema. Basically the patient has chronic hypertension but it will more evident because of the continuous decrease renal blood flow and pressure that stimulate the macula densa that will later on stimulate the adjacent juxtamedullary cell to release renin to the blood and will react with angiotensinogen directly released from the liver and will give rise to angiotensin I. Angiotensin I will be converted to angiotensin II by the angiotensin converting enzyme from the pulmonary and renal endothelium. Angiotensin II is a potent vasoconstrictor that will stimulate the efferent arteriole to constrict, it will stimulate the adrenal cortex to secrete aldosterone for water and sodium reabsorption that added to the blood volume, stimulation of the posterior pituitary gland by the angiotensin II will result to the release of antidiuretic hormone that synergistically promote sodium retention, and angiotensin II also stimulate the sympathetic nervous system that will send signals for vasoconstriction. All of these mechanisms of angiotensin II will give rise to elevated blood pressure.

Hypertensive Nephropathy2014 [email protected] | 10

LABORATORY AND DIAGNOSTIC TESTS Blood Test Hematocrit (Hct) Test Imagine red blood cells as the subway system of your blood. They transport oxygen and nutrients to various locations in your body, making their role vital to your health. Your body relies on the correct proportion of red blood cells for you to stay healthy. If your physician suspects you have too few red blood cells, a hematocrit or Hct test may be ordered. This simple blood test can reveal the proportion of red blood cells in your blood. Purpose. A hematocrit test can help your doctor diagnose you with a particular condition or it can help him or her determine how well your body is responding to a particular treatment. While the test can be ordered for a variety of reasons, its often used to test for anemia, leukemia, dehydration, or dietary deficiencies. Preparation. Let your doctor know if you have undergone a blood transfusion recently, as this may affect your results. Pregnancy also can decrease your blood urea nitrogen (BUN) levels due to increased fluid in your body. If you live at a high altitude, your hematocrit levels tend to be higher due to reduced amounts of oxygen in the air. A medical provider will need a small sample of blood to test your hematocrit. This blood can be drawn from a finger prick or taken from a vein in your arm. Blood will collect in a slim vial known as a pipette or in a larger tube. Result. While the laboratory that tests the blood the sample may have its own ranges, generally accepted ranges for hematocrit depend on your gender and age. According to the Mayo Clinic, typical ranges are as follows Adult men: 38.8 to 50 percent Adult women: 34.9 to 44.5 percent Low hematocrit levels can indicate: bone marrow diseases, chronic inflammatory disease, deficiencies in nutrients such as iron, folate, or vitamin B12, internal bleeding, hemolytic anemia, kidney failure, Leukemia, lymphoma, sickle cell anemia. High hematocrit levels can indicate: congenital heart disease, dehydration kidney tumor, lung diseases, polycythemia vera. Glomerular Filtration Rate Test Your kidneys are the bodys main filtration system, removing waste products from your blood and releasing them via your urine. The small filters inside your kidneys are known as glomeruli. If your kidneys are not working properly, your glomeruli will not filter as quickly. Your doctor may order a glomerular filtration rate (GFR) test if he or she suspects your kidneys may not be working properly.

Hypertensive Nephropathy2014 [email protected] | 11

Purpose. Since the GFR test can indicate how well your kidneys are functioning, the test is ordered when you have symptoms related to kidney disease or when your doctor wants to test the effectiveness of a particular treatment. According to the American Associationfor Clinical Chemistry, examples of kidney disease symptoms include unexplained body swelling, foamy urine, difficulty urinating, and mid-back pain. (AACC) Early intervention is vital to preventing further kidney damage, which is why your physician may recommend a GFR test if you have the following conditions: Diabetes, recurring urinary tract infections, hypertension, heart disease, urinary blockage. If your doctor has diagnosed you with kidney disease, the GFR test can help diagnose how well your kidneys are functioning. If you have a family history of kidney disease, your doctor may want to run a GFR test to get a sense of the current state of your kidneys. Preparation. The GFR test involves taking a blood sample to test for creatinine. This substance is a waste product your kidneys filter and release in the urine. If you have high amounts of creatinine in your blood, this can indicate that your kidneys are not filtering adequately. Your doctor or nurse will obtain a sample by drawing blood from your arm. Because GFR is calculated using a specific formula, whoever draws the blood will also ask you relevant information, such as: age, gender, race, height, weight A laboratory specialist will take these factors into account to calculate the most accurate GFR.

Result. The GFR test is sometimes known as the estimated GFR or eGFR test because several calculations are required to arrive at your final GFR. This is why the GFR test is considered an indirect measurement of how well your kidneys may be functioning. The following are typical GFRs, according to the National Kidney Foundation and American Association for Clinical Chemistry: healthy adults: 90 mL/min/1.73 m2 or higher children and the elderly: 60 to 89 mL/min/1.73 m2 early kidney disease: 60 to 89 mL/min/1.73 m2 for three months or more along with signs of kidney damage chronic kidney disease: less than 60 mL/min/1.73 m2 for three months or more kidney failure: less than 15 to 60 mL/min/1.73 m2 (NKF) Note that many different calculations are available for testing GFR. Your results may vary from the numbers listed above, depending on the laboratorys testing ranges. Your doctor will likely recommend taking your GFR over the course of several months to establish a pattern. Certain medications can affect your creatinine levels. You should notify your physician if you are taking any of the following medications: cephalosporin or aminoglycoside antibiotics, flucytosine, cisplatin, cimetidine, trimethoprim.

Hypertensive Nephropathy2014 [email protected] | 12

Urine Test Microalbuminuria Test The kidneys are responsible for removing waste products from the blood and regulating the water fluid levels. When damage to the kidneys occurs, this pair of organs may fail to filter out wastes. Additionally, damaged kidneys may fail to retain nutrients and proteins from the body that are essential to health. Such is the case with albumin. Albumin is a protein that is used by the body for normal cell growth and tissue repair. If the kidneys become damaged, they may not retain this protein within bloodstream causing it to be excreted with the urine. When this occurs you may experience serious health complications. Maintaining normal kidney function is vital to ensuring that albumin remains in the bloodstream. The microalbuminuria test is a urine test that measures the amount of albumin in your urine. If kidney damage has occurred, albumin will leak into the bloodstream and will be present in the urine. The microalbuminuria test is also known as: the ACR test the albumin-to-creatinine ratio test the urine albumin test Purpose. The purpose of the microalbuminuria test is to measure the amount of albumin in the urine. The test is typically used in conjunction with a creatinine test to provide an albuminto-creatinine ratio. Creatinine is a waste product in the blood that should be removed by the kidneys. When kidney damage occurs, creatinine levels in the urine decrease while albumin levels may increase.Measuring the amount of albumin in the urine is important for detecting the presence of kidney damage. Kidney damage can lead to kidney failure, requiring the patient to undergo dialysis. By identifying kidney damage before it results in kidney failure, your doctor can slow the progression of the disease to preserve kidney function over the long term. Preparation. No special preparation is needed for the test. Result. The results of the microalbuminuria test will vary, depending on the laboratory where the sample was analyzed. Normal values are typically less than 30 mcg/mg (micrograms per milligram) A low level of albumin in the urine is an indication that your kidneys are functioning normally. If an abnormal result is reported, your doctor will have you complete the microalbuminuria test again to confirm the results. Dehydration and high levels of exercise may increase albumin levels in the urine. As such, the results must be confirmed through additional testing. Based on the results from the microalbuminuria test, your doctor will be able to determine the extent of the kidney damage that has occurred. The results will also enable your doctor to provide appropriate treatment for kidney damage and its underlying cause.

***N-Acetyl-beta-D-Glucosaminidase (NAG) N-Acetyl-/-glucosaminidase (NAG) is a high molecular-weight (140 kDa) hydrolytic lysosomal enzyme that is found in many tissues of the body. It breaks chemical bonds of
Hypertensive Nephropathy2014 [email protected] | 13

glycosides and amino sugars that form structural components in many tissues. It is necessary for the degredation and disposal of various parts of the cell, including the cell membrane. NAG present in high concentration in the lysosomes of proximal renal tubular cells. There are two main isoenzymes found in human kidneys. Isoenzyme-A is part of intralysosomal compartment excreted in urine due to exocytosis. Isoenzyme-B is associated to the lysosomal membrane and excreted in urine during tubular damage. These two enzymes differ in their heat sensitivity and stable in acid urine. Result. An increased urinary N-acetyl-beta-D-glucosaminidase (NAG) activity might reflect increased lysosomal activity in renal tubular cells. Increase in lysosomal turnover and urine NAG activity, occurs when increased protein is presented to the tubular cells. Urine NAG activity is thus a measure of altered function in the renal tubules and not simply an indicator of damage. Measurement of Urinary NAG Activity. NAG activity was measured in the urine by a colorimetric assay (Boehringer Mannheim, Mannheim, Germany). In brief, this method uses the substrate 3-cresolsulfonphthaleinyl-N-acetyl--D-glucosaminidine-sodium, which is hydrolyzed by NAG when present in the urinary sample. This reaction releases 3-cresolsulfonphthaleinsodium, which is measured by spectrophotometry. According to the manufacturers instructions, 1 ml of the substrate solution was incubated for 5 min at 37C. A 50-l aliquot of the urinary sample then was added to the substrate solution, mixed, and incubated for 15 min at 37C. After incubation, 2 ml of the stop reagent solution that contained sodium carbonate was added to the sample mixture and allowed to stand for 10 min at room temperature. The absorbance then was measured by a spectrophotometer (Beckman Coulter, Fullerton, CA) set at 580 nm. A single measurement was performed per sample. The inter- and intra-assay coefficients of variation were 4.3 and 6.0%, respectively. Results were normalized to urinary creatinine values and expressed in mU/mg creatinine. NURSING THEORY Jean Watsons Philosophy and Science of Caring (Human Caring Science) The major elements that constitute Watsons continually evolving theory are: Caritas processes Transpersonal caring relationships Caring moments/caring occasions Caritas Process 1st Caritas: Humanistic-Altruistic System of Values- These values are learned early in our life. In sustaining humanistic-altruistic values in order to be compassionately available for others, we need to be loving and kind in our self first. Also, we need to be soft and tender to ourselves, so that we can have compassion to other person.

Hypertensive Nephropathy2014 [email protected] | 14

2nd Caritas: Faith and Hope- It facilitates the promotion of holistic nursing care and positive health within the patient (Tomey 2004). We should work in the patients belief system and not in our belief system, because we need to connect with them with our presence. One of the examples of Jean Watson, we should have a ritual (a 30 minute pause) to clean our mind and attract the good source or energy. Also, we can able to radiate faith, hope, caring, and compassion not only to our patient for ourselves. 3rd Caritas: Sensitivity to self and others- The recognition of feelings leads to selfactualization through self-acceptance for both the nurse and the patient (Tomey 2004). We should have an ongoing spiritual development for ourselves so that we can actually attend to be sensitive to another human being. According to Jean Watson, The 3rd Caritas is the foundation and core to caritas processes and caring-healing relationships. How to be sensitive to self and others? We should have a 30 minute pause in order for us to catch our emotions and honor them, so that we can release them. We can also envision ourselves that we are surrounded or protected by light (God). 4th Caritas: Caring Relationships- A trusting relationship promotes and accepts the expression of both positive and negative feelings. It involves congruence, empathy, nonpossessive warmth, and effective communication (Tomey 2004). In this caritas, we should have a deeper understanding of consciousness and intentionality as a nurse, because it invites us to be human, humane, open-hearted, more compassionate, more sensitive, and more capable as a human. The caring-healing relationship might be the intervention so we cannot dismiss the caring-healing relationship. We need to sustain it by thinking that this is a COMMITMENT, not a TECHNIQUE. Also, this is about authentic presence and a presence of intentionality, that we are ready to listen. One of the failures of a relationship is not acknowledging the person and being insensitive, we need to listen to their heart and our heart so that there is human to human connection. 5th Caritas: Positive and Negative Feelings- The sharing of feelings is a risk-taking experience for both nurse and patient. The nurse must be prepared for either positive or negative feelings (Tomey 2004). In a simple way, feeling is universal. We have our own positive and negative feelings. We need to allow them to express it in a safe space, so that we are not reacting and responding in a judgmental way. As a result, they are able to find clarity and options. 6th Caritas: Revisiting Evidence and Problem-Solving- Use of the nursing process brings a scientific problem-solving approach to nursing care. The nursing process is similar to the research process in that it is systematic and organized (Tomey 2004). We need to see other evidences and see our clinical judgments, experiences, intuition and ethical ways to create a solution. 7th Caritas: Teaching-Learning-Coaching- This caritas is important concept for nursing because it separates caring from curing. The nurse facilitates this process with teaching-learning techniques that are designed to enable patients to provide self-care, determine personal needs, and provide opportunities for their personal growth (Tomey 2004). We can say that caring relationship is the core of teaching-learning-coaching concept. This is not about the old teachingHypertensive Nephropathy2014 [email protected] | 15

learning model that gives information; this is about being in a relation of caring-healing model for another person from teaching-learning model to caritas coaching. When we say caritas coaching, it moves us to very specific skills, assisting the person, finding the best solution, best options, strategies in order for them to identify their needs. 8th Caritas: Healing Environment- Nurses must recognize the influence that internal and external environments have on the health and illness of individuals (Tomey 2004). The nurse is the healing environment, because we incorporate our heart in caring patients. According to Nightingale, if the environment is clean, comfortable and safe that is healing environment. We are the ultimate environment with the consciousness, intentionality and energetic presence that affect the patients well-being. 9th Caritas: Nursing as a Sacred Science- the nurse recognizes the biophysical, psychophysical, psychosocial, and intrapersonal needs of self and patient. Patients must satisfy lower-order needs before attempting to attain higher-order needs. Food, elimination, and ventilation are examples of lower-order biophysical needs, whereas activity, inactivity and sexuality are considered lower-order psychophysical needs. Achievement and affiliation are the higher-order psychosocial needs. Self-actualization is a higher-order intrapersonal-interpersonal need (Tomey 2004). As a nurse, we make sure that our patients satisfy lower-order needs to achieve higher-order needs. As we work with other life, we restore the dignity, integrity, and preserve the wholeness of a person. 10th Caritas: Allowing for miracles- phenomenology describes data of the immediate situation that help people understand the phenomena in question. Existential psychology is a science of human existence that uses phenomenological analysis. Watson believes that nurses have the responsibility to go beyond the 10 carative factors and to facilitate patients development in the area of health promotion through preventive health actions (Tomey 2004). For me, this caritas is the most difficult to understand but as nurses we should teach patients personal changes to promote health, provide support, teach problem-solving methods and recognize coping skills and adapt to loss. As nurses, we should open our mind and heart to mystery and allow miracles to enter. Transpersonal Caring and the Caring Moment Transpersonal caring relationships are the foundation of the work; transpersonal conveys a concern for the inner life world and subjective meaning of another who is fully embodied, but transpersonal also goes beyond the ego self and beyond the given moment, reaching to the deeper connections to spirit and with the broader universe. Transpersonal caring implies that the nurse consciously focuses on the uniqueness of self, other, and the present moment, wherein the nurse/client exchange is mutual and reciprocal, each fully embodied in the moment, while paradoxically capable of transcending the moment and opening to new possibilities. Transpersonal caring calls for personal reflection and an ability on the part of the nurse to be mindfully present to self and others. The transpersonal nurse has the ability to center consciousness and intentionality on caring, healing, and wholeness, rather than on disease, illness and pathology. The authentic transpersonal caring exchange will potentiate comfort measures,
Hypertensive Nephropathy2014 [email protected] | 16

pain control, a sense of well-being, wholeness, and/or even spiritual transcendence of suffering. The person is viewed as whole and complete, regardless of illness or disease (Watson, 2012). Transpersonal caring-healing relationship is considered space not a technique or something one does to other; it is a process related to philosophic, moral and spiritual foundation; it is also a relational ontology that is life giving and life enriching for both. A caring moment consists of actions and choices made by both the nurse and patient. The moment of coming together presents them with the opportunity to decide how to be in the moment and in the relationship as whereas what to do with and during the moment. If the caring moment is transpersonal, the client and nurse feel connected with one another at the spiritual level, thus the moments in the interaction transcend time and space and open up new possibilities for healing and human connection at a deeper level than physical, social, or verbal interaction. However, a caring occasion occurs whenever the nurse and another come together with their unique life histories and phenomenal fields in a human-to-human interaction. The coming together in a given moment becomes a focal point in space and time. It becomes transcendent whereby experience and perception take place, but the actual caring occasion has a greater field of its own in a given moment (Watson 2012). A good nurse cannot be defined solely by his/her ability and skills but how well he/she interacts with the client and family while providing care. I agree with Jean Watson and feel that the contact and the bond between two individuals is the foundation of nursing. As nurses, we provide caring and thoughtful approach to promote holistic health and prevent illness. A good nurse cannot be defined solely by his/her abilities and skills but also by how well he/she interacts with the client and family, while providing care. Throughout nursing history, the public image of nursing is this, a woman giving sponge baths and cleaning bed pans. These stereotypes are ones that are negative to our profession and the need to instill a new image is vital. The need is to harmonize and seek a balance between professional images of nurses yet maintain our caring/nurturing image. Jean Watson feels that vital aspect of nursing is spirituality. Nurses must be at one with the past, present and future to attain the ultimate of caring. We must grow as a nurse and seek out the essence of nursing (Caring). Indeed, the theory of human caring is timeless in the profession of nursing and society. Faye Glenn Abdellahs Twenty-one Nursing Problems Faye Glenn Abdellah is the proponent of the twenty-one nursing problems that has great effect and results to better changes in nursing education (in terms of the curriculum and established unique body of knowledge in nursing as a profession) and practice in hospital and community setting. In line with this nurses should always know the scientific basis or rational in every skills that she/he possesses. Abdellahs theory was used to evaluate nurses performance in the practice and it was also used as a basis of development of diagnostic related group (DRG) in 1983. The following are the Typology of 21 Nursing Problems: Basic to All Patients To maintain good hygiene and physical comfort.
Hypertensive Nephropathy2014 [email protected] | 17

To promote optimal activity: exercise, rest and sleep. To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection. To maintain good body mechanics and prevent and correct deformity. Sustenal Care Needs To facilitate the maintenance of a supply of oxygen to all body cells. To facilitate the maintenance of nutrition of all body cells. To facilitate the maintenance of elimination. To facilitate the maintenance of fluid and electrolyte balance. To recognize the physiological responses of the body to disease conditions. To facilitate the maintenance of regulatory mechanisms and functions. To facilitate the maintenance of sensory function. Remedial Care Needs To identify and accept positive and negative expressions, feelings, and reactions. To identify and accept the interrelatedness of emotions and organic illness. To facilitate the maintenance of effective verbal and non verbal communication. To promote the development of productive interpersonal relationships. To facilitate progress toward achievement of personal spiritual goals. To create and / or maintain a therapeutic environment. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs.

Restorative Care Needs To accept the optimum possible goals in the light of limitations, physical and emotional. To use community resources as an aid in resolving problems arising from illness. To understand the role of social problems as influencing factors in the case of illness. It is not only applicable in caring patients with Renal Disease but it is applicable to all disease condition. Holistic application of the 21 Nursing Problems identified by Abdellah makes nurses competent in providing compassion and excellent nursing care to the patient as the center and recipient of care. Nurses today became more competent due to not only doing procedures as part of nursing care but also understanding its scientific basis. In line with this, nurses are more knowledgeable and confident in relating the purposes of every action that are being rendered to the patient as the center of the provision of care. It is now proper and just to say that because of the typology of 21 nursing problems nurses practice is organized and systematic in nature. The so called nursing process: assessment, nursing diagnosis, and planning intervention is based on Abdellahs model.

Hypertensive Nephropathy2014 [email protected] | 18

NURSING DIAGNOSES Actual Diagnoses Ineffective Tissue Perfusion related to decreased renal blood flow. Excess Fluid Volume related to compromised regulatory mechanisms of the kidney. Risk Diagnoses Risk for Pulmonary Edema related Risk for Electrolyte Imbalances Health Promotion Diagnoses Readiness for enhanced management of therapeutic regimen related to noncompliance with or nonadherance to treatment. Readiness for enhanced nutrition related to noncompliance on the prescribed diet. NURSING INTERVENTIONS Ineffective Tissue Perfusion: Renal related to decreased renal blood flow. Goal: After 8 hours of nursing care the patient will able to identify necessary lifestyle changes to control blood pressure at normal level. Diagnostic Monitor the patients blood pressure at regular intervals, based on condition in supine, sitting, and standing position. Encourage client to share feelings, concerns, and understanding of risk factors, disease process, and effect on life. Therapeutic Assist client to select lifestyle behaviors that he or she chooses to change by considering personal abilities, resources, and overall health and to be realistic and optimistic. Administer renin inhibitor (Aliskiren) as ordered to inhibit RAAS activation. Educative Educate the patient about the disease, its treatment, and control. The goals of treatment are to control blood pressure, reduce risk of complications, and use the minimum number of drugs with lowest dosage necessary to accomplish control. Stress that hypertension is chronic and requires persistent therapy and mandatory follow-up health care visits. Explain the pharmacologic control of hypertension. Discuss possible adverse effects of drugs.

Hypertensive Nephropathy2014 [email protected] | 19

Excess Fluid Volume related to compromised regulatory mechanisms of the kidney. Goal: After 8 hours of nursing care edema will subside and the patient will have an almost equal volume of fluid intake and fluid output. Diagnostic Monitor the patients blood pressure at regular intervals, based on condition in supine, sitting, and standing position. Monitor patients weight and diet. Weigh the patient daily to provide an index of fluid balance; expected weight loss is to 1 lb (0.3 to 0.5 kg) daily. Monitor laboratory results for changes in kidney function and electrolyte levels due to hypertension and to drug therapy. Monitor for signs and symptoms of hypovolemia or hypervolemia because regulating capacity of the kidneys is in adequate. Therapeutic Adjust fluid volume intake to avoid volume overload and dehydration: a. Fluid restriction is not usually initiated until renal function is quite low. b. Fluid allowance should be distributed throughout the day. c. Restrict sodium and water intake if there is evidence of extracellular excess. Employ intensive pulmonary hygiene because incidence of pulmonary edema and infection is high. Educative Educate the patient about the disease, its treatment, and control. The goals of treatment are to control blood pressure, reduce risk of complications, and use the minimum number of drugs with lowest dosage necessary to accomplish control. Advise patient to follow a low-sodium diet and enlist his or her cooperation in redirecting lifestyle in keeping with therapy guidelines.

COMPLICATION Uncontrolled hypertension can accelerate the decline of renal function in patients affected with hypertensive nephropathy, if less than 1/3 of the nephrons in both kidneys are left functioning it will lead to Chronic Renal Insufficiency; however, whether mild-to-moderate essential hypertension can cause Chronic Kidney Disease. On other words hypertensive nephropathy is a gateway in developing Chronic Kidney Disease if not promptly managed. PROGNOSIS With regard to the target BP, the Working Group Report on Hypertension and Diabetes recommended a BP goal of less than 130/80 mm Hg to preserve renal function and to reduce cardiovascular events in patients with hypertension and diabetes. Lower BPs are recommended for patients with proteinuria greater than 1 g/d and renal insufficiency, regardless of etiology.
Hypertensive Nephropathy2014 [email protected] | 20

The optimal BP goal to slow the progression of renal failure in patients with hypertensive nephrosclerosis currently is unknown. Hypertensive nephrosclerosis remains a poorly defined entity. Researchers continue to search for a clear definition, a pathophysiologic mechanism, and optimal treatment for patients with this condition. As suggested by Meyrier (1996), hypertensive nephrosclerosis may conceivably be a primary microvascular nephropathy. Medical treatment is indicated in patients younger than 80 years with BP higher than 140/90 mm Hg. In these patients, antihypertensive treatment has proven to reduce the risk of stroke and cardiovascular mortality.

Hypertensive Nephropathy2014 [email protected] | 21

REFERENCES Books Ignatavicius, D. D. & Workman, M. L. (2006). Medical Surgical Nursing: Critical Thinking for Collaborative Care. 5th Ed., Vol. 1. Elsevier: Singapore. Kumar, V., Abbas, A. K., & Fausto, N. (2005). Robbins and Cotran Pathologic Basis of Disease. 7th Ed., Elsevier, Inc., Philadelphia, PA, USA. Ladwig, G. B. & Ackley, B. J. (2008). Guide to Nursing Diagnosis. 2nd Ed., Mosby, Inc., Missouri, USA. Nettina, S. M. (2006). Lippincott: Manual of Nursing Practice Handbook. 3rd Ed., Lippincott Williams and Wilkins. Tortora, G. J. & Derrickson, B. H. (2009). Principles of Anatomy and Physiology. 12th Ed., Vol. 2. John Wiley & Sons: Asia. Web (Internet) Fervenza, F. C., Textor, S. C., Zand, L., & Rosenthal, D. (November 15, 2013). Nephrosclerosis. Retrieved February 02, 2013 from http://emedicine.medscape.com/article/244342-overview Healthline (August 20, 2012). Creatinine Blood Test. Retrieved February 05, 2014 from http://www.healthline.com/health/creatinine-blood#Overview Kidney Cares Community. Hypertensive Nephropathy. Retrieved February 02, 2014 from http://www.kidney-cares.org/hypertensive-nephropathy/ Wikipedia (January 21, 2014). Hypertensive Nephropathy. Retrieved February 02, 2014 from http://en.wikipedia.org/wiki/Hypertensive_nephropathy

Hypertensive Nephropathy2014 [email protected] | 22

APPENDIX

Figure 1 Microscopic Anatomy of Glomerulus

Figure 2 Renal Blood Flow

Hypertensive Nephropathy2014 [email protected] | 23

Figure 3 Concept Map of Renal Blood Flow

Figure 4 Urine Formation

Hypertensive Nephropathy2014 [email protected] | 24

Figure 5 Healthy Kidney VS. Diseased Kidney (Hypertensive Nephropathy)

Figure 6 Hypertensive Nephropathy

Hypertensive Nephropathy2014 [email protected] | 25

HEALTH PROMOTION PROGRAM Goal: The program is designed to encourage patients with Kidney disease to strictly adhere and comply on the treatment regimen to slow the progression of the disease and also serves as preventative measure to those who have family history of Kidney disease. Participants: Patients Diagnosed with any form of Kidney disease and the family members who are at risk. Objectives: At the end of the Health Promotion Program/Activities the participants will be able to: Cognitive Domain Describe the kidney on their words based on the presented animation. Name the different basic anatomical structure of the kidney as they refer on the provided illustration. Discuss the major physiology of the kidney or urinary system relating it on their disease condition. Identify health measures to prevent and to slow the progression of the disease process based on the discussed major physiology of the urinary system. Psychomotor Domain Observe the different ways to prepare healthy meals as they imitate what is being demonstrated by the nutritionist and dietitian. Follow different instructions about the executed exercises as they participate during the demonstration. Precisely demonstrate the proper way of blood pressure taking and monitoring through demonstrating it with co-participants. Holistically monitor their weight through return demonstration following the special considerations while taking their baseline data of their weights. Confidently show the proper way of medication administration as they simultaneously take their prescribed and due medications during the daily activities. Affective Domain Demonstrate awareness about their disease condition as they holistically adhere on the therapeutic treatment regimen through maintaining blood pressure and sugar level within normal ranges. Righteously commit on living the learned healthy measures to prevent and slow the progression of the disease through attending the set activities of health promotion program and actively participate to the formed group with the different upcoming health promotion activities.

Hypertensive Nephropathy2014 [email protected] | 26

Persuasively encourage other patients with kidney disease and their relatives, and healthy clients to actively participate on the health promotion program as they live as a good example through giving them the chance to facilitate the program. Establish harmonious organization through continuing the introduced health promotion program and developing other activities to boost the confidence of each member, monitoring their compliance on the treatment regimen and being recognized as formal organization by health care providers.

Schedule of Activities Day 1 Time Duration 1-2 hours

Activities Personal interview and assessment of goal. Audio Visual Presentation of animated cartoon of Kidneys portraying about the basic anatomical structure and its respective physiology in different languages Video Clip of the actual Urinary System using lay mans term as possible. Art activity about Kidney, expressing their emotion on the day Short discussion about the Audio-Visual, Video Clip and Art activity. Establish baseline data: Weight, Urinalysis, BP taking, Blood Glucose monitoring Short discussion about Medication

Materials/Equipment/ Venue TV set Laptop and power point projector Art materials: pencil, crayon, bond paper, colored paper, small pieces of cloth, set of tailoring materials, T-shirt. Audio-Visual Room/Multipurpose Hall/Ward

Facilitator Registered Nurse Artist Psychologi st Nephrologi st

Day 2 1-2 hours

Nursing paraphernalia: BP apparatus, glucometer, weighing scale, urine specimen

Registered Nurse Physical Therapist/G ym Instructor

Hypertensive Nephropathy2014 [email protected] | 27

administration Exercise Activities for at least 30 minutes (e.g. Aerobics, Dancing, Zumba, Meditation) Meal/snack preparation specifically indicated for the disease.

Day 3 1-2 hours Daily monitoring of BP Daily sharing about the packed snack Self-awareness activity

container Sample Medicines TV /stereo set Fruits and vegetables, condiments (c/o the Nutritionist and Dietitian) Containers

Nutritionist Dietitian

Nursing paraphernalia: BP apparatus Material needed for self-awareness (c/o the Psychologist)

Registered nurse Psychologi st

Day 4 1-2 hours

Daily monitoring of BP Daily sharing about the packed snack Self-awareness activity (continuation) Exercise Activities for at least 30 minutes (e.g. Aerobics, Dancing, Zumba, Meditation) Daily monitoring of BP, Blood Glucose, Weight Urinalysis Daily sharing about the packed snack Exercise Activities for at least 30 minutes (e.g. Aerobics, Dancing, Zumba, Meditation) Reflection Promotion of online educational resources, and daily SMS reminder

Nursing paraphernalia: BP apparatus, Material needed for self-awareness (c/o the Psychologist)

Registered nurse Psychologi st Physical Therapist/G ym Instructor

Day 5 1-2 hours

Nursing paraphernalia: BP apparatus, glucometer, weighing scale. Material needed for self-awareness (c/o the Psychologist)

Registered nurse Physical Therapist/G ym Instructor Nephrologi st

Hypertensive Nephropathy2014 [email protected] | 28

***for to-go-home (discharged) patients, there will be distribution of CD about the exercise and comics about the kidney and the disease process, advised for unscheduled weekly home visit by the nurse for monitoring and counseling and reiteration of the personal goal. ***There will be monthly general assembly for discharged patient and those who completed the program for re-evaluation, counseling and socialization, and further evaluation of the impact of the program for its improvement. ***after sufficient evaluation through monitoring and counseling of the discharged patients, they will be invited to take part on the Health Promotion Program.

THE PROGRAMME DAY 1 07:45AM 08:00AM Registration 08:00AM 08:05AM Opening Prayer 08:05AM 08:20AM Brief Orientation (c/o Renal Nurse) 08:20AM 09:00AM Personal Assessment (c/o Psychologist) 09:00AM 09:30AM Audio-visual Presentation 09:30AM 10:00AM Art Activity (c/o Artist) 10:00AM 10:30AM Brief Discussion (c/o Nephrologist and Renal Nurse) 10:30AM 10:35AM Concluding Prayer DAY 2 07:45AM 08:00AM Registration 08:00AM 08:05AM Opening Prayer 08:05AM 08:20AM Taking Baseline Data (c/o Renal Nurse) 08:20AM 09:00AM Short Discussion About Medication Administration (c/o Renal Nurse) 09:00AM 09:30AM Physical Exercise (c/o Physical Therapist) 09:30AM 10:00AM Meal/Snack Preparation (c/o Nutritionist and Dietitian) 10:00AM 10:20AM Concluding Prayer and Refreshment DAY 3 07:45AM 08:00AM Registration 08:00AM 08:05AM Opening Prayer 08:05AM 08:20AM Daily Monitoring of BP (c/o Renal Nurse) 08:20AM 09:05AM Self-awareness Activity (c/o Psychologist) 09:05AM 09:20AM Daily Sharing about the Packed Snack 09:20AM 09:40AM Concluding Prayer and Refreshment DAY 4 07:45AM 08:00AM Registration 08:00AM 08:05AM Opening Prayer 08:05AM 08:20AM Daily Monitoring of BP (c/o Renal Nurse) 08:20AM 09:05AM Self-awareness Activity - continuation (c/o Psychologist)
Hypertensive Nephropathy2014 [email protected] | 29

09:05AM 09:35AM Physical Exercise (c/o Physical Therapist) 09:35AM 09:55AM Daily Sharing about the Packed Snack (c/o Participants) 09:55AM 10:15AM Concluding Prayer and Refreshment DAY 5 07:45AM 08:00AM Registration 08:00AM 08:05AM Opening Prayer 08:05AM 08:20AM Monitoring of BP, BG, Wt. (c/o Renal Nurse) 08:20AM 08:50AM Physical Exercise (c/o Physical Therapist) 09:05AM 09:50AM Reflection (c/o Psychologist) 09:50AM 10:10AM Daily Sharing about the Packed Snack (c/o Participants) 10:10AM 10:30AM Refreshment and Promotion of Online Educational Resources (Website) and Reminders (c/o Nephrologist and Renal Nurse) 10:30AM 10:35AM Concluding Prayer ***The set of activities is subjected to adjustment and improvement based on the suggestion of the immediate Supervisor and the involved Facilitators.

Hypertensive Nephropathy2014 [email protected] | 30

CONCEPT MAP
Chronic Primary Hypertension

Genetic: APOL1 Gene Variant

Susceptible to Glomerular Damage Afferent Arteriole Hyperactivity

-Afferent Arteriole Vasoconstriction -Efferent Arteriole Vasodilation

*Glomerular Necrosis Hyperplastic Arteriolitis /Hyaline Arteriosclerosis

Regulated Glomerular Pressure

Decreased Glomerular Blood Flow

Compensatory Mechanism

Stimulated Juxtamedullary Cell

Glomerular Ischemia

Release of Renin

GLomerular Atrophy and Hyalinization

RAAS Activation *Glomerular Necrosis

BP Measurement

Hypertension

Decreased Efferent Arteriole Blood Flow Altered Renal Physiology Efferent Arteriole Ischemia

Ineffective Tissue Perfusion

RBC Leak

Protein Leak

Efferent Arteriole Atrophy and Hyalinization Hematuria Urinalysis Proteinuria

Decreased Renal Tubules Blood Flow

LEGEND

Ineffective Tissue Perfusion

Decreased Oncotic Pressure Renal Tubules Necrosis

ETIOLOGY Physical Assessment Edema

PATHOGENESIS Fluid Volume Excess

MORPHOLOGICAL CHANGES Risk for Pulmonary Edema

CLINICAL SIGNIFICANCE

NURSING DIAGNOSIS

DIAGNOSTIC METHOD

PHYSIOLOGY

Refer to the Pathophysiology Section (page 08) for its explanation.

Hypertensive Nephropathy2014 [email protected] | 1