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8/8/2019 Case Pres .Med Ward
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I.Acknowledgement
This case presentation would not be possible without the strenght,
wisdom and guidance given to us by Almighty God in which help us the
fulfillment of this study.
To our patient,whom we greatly avknowledge her cooperation and
willingness in every nursing intervention we render and every health
teaching we said.
We would like to extend our deepest gratitude to our clinical instructor
Ms. Sandra Loberiano for granting us the opportunity in conducting a casepresentation.Through this we further enhance our knowledge and able to
practice the skills we learned in rendering quality nursing care.We thank
her patience and advices to keep us strong and focus to our case
presentation and in every nursing activity we done to our patient.
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II.Introduction
Chronic Kidney Disease (CKD,also called chronic renal failure or chronic renalinsufficiency) is defined as a structural or functional kidney abnormality that persist for atleast three months or a chronic and significant decrease in kidney function.
Some people with CKD have normal kidney function ( the kidneys are able tofilter and excrete easte products in the urine) and do not have a reduction in kidneyfunction over time.In other people cKD causes a reduction in the level of kidneyfunction, which declines further over time.A number of conditions can cause CKD anddetermining the cause can help determine the optimal therapy to slow the damage ofCKD.However some patients with CKD will eventually require dialysis or kidneytransplantation.
Renal insuffiency is a common feature of chronic TIN and its diagnosis must be
considered in any patient who exhibits renal insufficiency.In most cases howeverchronic TIN is insidious in onset, renal insuffiency is slow to develop and earliestmanifestation of the disease are those of tubular dysfunction.As such,it is important tomaintain a high index of suspicion of this entity whenever any evidence of tubulardysfunction is detected clinically.At this early stage removal of a toxic cause of injury orcorrection of the underlying systemic or renal disease can result in preservation ofresidual renal function.Of special relevance in patients who exhibit renal insufficiencycaused by primary TIN is the absence or modest degree of the two principal hallmarksof glomerular and vascular diseases of the kidney,salt retention manifested by edemaand hypertention anvd proteinuria which usually is modest and less than 1 to 2 g/d in
TIN.These clinical considerations notwithstanding a definite diagnosis of TIN can beestablished only by morphology of kidney tissue.
People with chronic kidney disease suffer from accelerated atherosclerosis andare more likely to develop cardiovascular disease than general population.Patientsafflicted with chronic kidney disease and cardiovascular disease tend to havesignificantly worse prognoses than those suffering only from the latter.In many CKDpatients previous renal disease or other underlying diseases are already known.a smallnumber presents with CKD of unknown cause.In these patients a cause is occationallyidentified retrospectively.
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IIII.Objective of the study
General Objective:
This study aims to be more knowledgeable about our patients condition and to
render quality nursing care in response to the specific disease.The primary goal of this study is to help us become competent in the basic
assessment and management of significant signs and symptoms in regards to chronickidney failure.
Specific Objectives:
y To distinguish chronic kidney disease in different stages.y To properly identified chronic kidney disease for proper assessment and
management.y To familiarize chronic kidney disease and render appropriate relief to this
kind of disease.
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IV.BIOGRAPHICAL DATA
Name: Patient X
Address: 152 Cadena de Amor St. Tondo Manila
Gender: Male
Birthday: June 4,1986
Religion: roman catholic
Nationality : Filipino
Attending Physician: Dra.Anceta/ Dr.Felipe
Date of Admission: February 8,2010. 5:00 pm
Admitting Diagnosis: Pleural effusion left. Chronic Kidney Failure
V.MEDICAL HISTORY
This is a case of 23 years old Filipino male was born on June 04, 1986 who
resides at Cadena de Amor St. Tondo Manila and who is a Roman Catholic. Admitted
on February 08, 2010 at 5:00 pm with chief complain of difficulty of breathing (DOB)
Vital signs taken as follows: BP: 140/110 mmHg, HR: 104 bpm, RR: 33bpm, T:37.7C.
His admitting diagnosis was pleural effusion left chronic kidney disease (CKD). He has
no previous hospitalization and no surgical operation; he has no known allergy to any
foods and medications. He has a family history of hypertension, heart disease, and
asthma. Last 2008 he had a chief complain of pain on his nape due to hypertension and
diagnosed of glumerulonephritis and he underwent to a hemodialysis regularly twice a
week before. He had no difficulty in urination or dysuria but sometimes he experienced
constipation. He doesnt smokes and drinks any alcoholic beverages.
Patients physical examination in hair, nail and head is normal; face is
symmetrical and no involuntary muscle movement. Eyes are in yellowish color noted
and ears, neck and tongue of patient is in normal. Chest and lungs moves symmetrically
with irregular breathing patterns. Abdomen and back area is in normal rhythm. Skin is
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normal in color and no jaundice noted and no evident of lesions in upper extremeties.
Patients lower extremeties have no presence of edema, masses, or varicous veins
noted.
VI.HISTORY OF PRESENT ILLNESS
The patient start complaining of Hypertension last 2008 with pain on the
back.Last week the patient is apparently well until last week he had difficulty in
breathing.
VII.PAST MEDICAL HISTORY
As Patient X was interviewed, the group had known that he has no known
allergies to food or medicine. He is negative for diabetes mellitus and is also negative to
pulmonary tuberculosis. When he gets sick, he usually gets well or rests at home. He
has not yet experienced being hospitalized before even with other illnessess. Patient X
has not been subjected to any surgical operations.
VIII.Family History
On patients mother side the most problem that they posess is being
hypertensive.Some members of the family also have an asthma.Cardiac problems is
most pronounced on his mothers side also.
IX.Personal and Social History
Patient doesnt smoke or drink alcoholic beverages.The main problem that he
exhibit is that he is fond of eating fatty and salty foods because he can resist the taste
of it.According to the mother of the patient he drinks ice tea and coffee more than the
usual intake with an average of 5 glasses a day.
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X.Assessment
A. REVIEW OF SYSTEM
Baseline Measurement/ Vital Signs
Blood Pressure: 140/110 mmHg
Pulse Rate: 104 bpm
Respiratory Rate:34 bpm
Temperature: 37.7C
y Head
Headache (-)
Head injury(-)
Seizures(-)
Fainting(-)
y Eyes
Blurred Vision(-)
Diplopia(-)
Glaucoma(-)
Cataract(-)
y Ears
Inspection(-)
Discharge: no discharge
Earache(-)
Tinnitus(-)
Vertigo(-)
y Nose
Epistaxis(-)
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Sinus Pain(-)
Allergy(-)
Post Nasal Discharge(-)
y Respiratory System
Difficulty of Breathing()
Asthma(-)
Shortness of Breathing(-)
Pain()
Tuberculosis(-)
y Cardiovascular System
History of Heart Murmurs(-)
Rheumatoid Fever(-)
Kawasaki Disease(-)
Hypertension()
Palpitation(-)
Anemia(-)
y Gastrointestinal system
Constipation()
Change in Bowel habits(-)
Rectal Pruritus(-)
Hemorrhoids(-)
Hepatitis(-)
Appendicitis(-)
y Genitourinary System
Urinary Tract infection(-)
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Hematuria(-)
Sexually Transmitted Disease(-)
Pelvic Inflammatory(-)
Hepatitis(-)
HIV(-)
Dysuria(-)
y Extremities
Varicose veins(-)
Pain or Stiffness of joint(-)
Any fracture or dislocations(-)
Edema(-)
Cyanosis(-)
Pallor(-)
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B.PHYSICAL EXAMINATION
Body Part Tools Findings Interpretation
Hair Inspection and
Palpation
-thick, black and fine
hair
-evenly distributed
-covering the whole
scalp
NORMAL
Head Inspection and
Palpation
-Head is
proportionate to
body
-No tendernessnoted upon
palpation
NORMAL
Face Inspection -face is symmetrical
and no involuntary
muscle movement.
NORMAL
Eyebrows Inspection -black evenly
distributed
NORMAL
Eyes Inspection and
Palpation
-symmetrical, non-
protruding
-equal palpebral
fissure
-no discharge and
discoloration
-cornea clean and
transparent()Corneal reflux
-iris no noted any
visible material
-black in color
NORMAL
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PERRLA
-yellowish sclera -Abnormal
Ears Inspection and
Palpation
- Facial skin
and aligned
outer canthus
of the eye
- No discharge
- Texture:
Elastic
- Hearing:
responds tonormal voice
NORMAL
Nose Inspection and
palpation
- Symmetric
and straight
- No lesions
- Non-tender
sinuses
NORMAL
Mouth (Lips teethand gums)
Neck
Inspection
Inspection and
palpation
-uniform pink colorsoft moist
-Smooth texture
-Complete teeth
-no receding gums
-with dental caries
-the neck is straight
with no visible mass
-symmetrical
NORMAL
NORMAL
Chest and Lungs Inspection and
palpation
-breathing pattern is
irregular
ABNORMAL
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Heart Auscultation - HR of 104
- Normal
rhythm
NORMAL
Upper extremities,
abdomen and lower
extremities
Inspection -Symmetrical
-no lesions
Normal skin color
-no evident of lesion
-no masses
-no edema
-no presence of
varicosities
NORMAL
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XI.GORDONS LEVEL OF FUNCTIONING
Gordons Level of
Functioning
Pre-
Hospitalization
During
Hospitalization
Interpretation
Eating Pattern The patient eats3 major meals ina day and snacksbetween themajor meals. Itsamount and thefrequency ofsnacks willdepend upon herappetite.
Since the diseasehas beendiagnosed, heneeds to limit theamount of foodand the there isrestriction
Foods areessential for thefunction of thebody becausefood givesnutrients andprovide energyfor the dailyactivities. Eatingnutritious foods
like vegetables,meat and fruitsare important toinclude in the diet
Drinking Pattern The patient drinksan average of 5cup of coffee andice tea and 8-10glasses of waterin a day.
In the hospital,the patient drinkswater only
Human bodycompose of 60-75 % of waterand enoughintake of waterare important forthe fluid and
electrolytebalance.EliminationPattern
The patient iscapable of goingto the bathroomon his own, ableto urinate anddefecate withoutpain butsometimesconstipated.
Even though heis on the hospital,he is able tourinate anddefecate withoutpain, however heneeds someoneto go with him,because of his
contraption
An alteration canbe seen in thepatientseliminationpattern is thedefecation,wherein there issometimesconstipation
Bathing Pattern The patient wasable to performhygienemeasures
The patient wasnot able to batheinstead he justsponge her body
Performingpersonal hygieneis important forprevention offurthercomplication byreducing the
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microorganism onthe body.
Sleeping Pattern The patientsleeps on time forat least 8 hours a
day.
The patient canno longer sleep atabout 8 hours in
a day and wasnot comfortablewith his situation.
The patients hasdisturbedsleeping pattern
due to hercondition
Activity/ExercisePattern
The patients doesnot have a job,instead he justhelp his motheron the householdchores
There is arestriction on hismobility due thepain he felt.
An alteration canbe seen on thepatients activityand exercise dueto hiscontraptions andthe pain.
Self-perception/
Self-conceptpattern
The patient
perceived hisbody asphysically fit andhealthy becausehe didnt noticeany sin andsymptoms ofdisease.
The patient
realized after allthat he isexperiencingsuch kind ofdisease and hasa positiveperception thatafter all this hislife together withhis family willback to normal
way.
Due to disease
he can comeback to hisnormal living withhis family.
Role/relationshippattern
The patient isalso a bredwinner in a littleway. According tohim he needs tosurvive and livelonger for hisfamily andfriends.
The patient wasclose to hisfamily.
The relationshipof the patienttowards familynever changed.
Coping stress/
Tolerance pattern
Whenever the
patient feels painthrough her bodyshe prefers totake a rest on hisown and takesome medicinesto relieve thepain. Sometimes
Sometimes the
patient was ableto voice out to thedoctor andnurses inside thehospital thosepains that he feltwith his body.
The patient is
now capable oftelling thosepains he feltwhen somebodyis asking.
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when his family isnot around hefelt alone andsad.
Spiritual pattern The patient
attended churchbut not allSunday
The patient is not
capable to go tochurch but hedon not forget topray.
He still believes
and have faith toGod the patient isactive when itcomes tospiritual concern.
XII.ANATOMY AND PHYSIOLOGY: The Kidneys
y The kidneys are two bean-shaped organs located retroperitoneally at the level of
12th thoracic and third lumbar vertebra.
y The right kidney is lower than the left kidney due to the presence of the liver on
the other right side of the abdomen.
y The kidneys are divided into renal cortex medulla and pelvis. The medulla is
composed of pyramids.
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y The functional units of the kidneys are the nephrons. The nephrons is composed
glomerumerulus and the renal tubules
y The primary function of the nephron is for urine formation.
y Through the formation of urine, the kidneys remove waste products from the
body, regulate fluid volume, and maintain electrolyte concentration, blood
pressure and pH within the body.
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XIII.PATHOPHYSIOLOGY
yGLOMERULONEPHRITIS HYPERTENSION
REMAINING NEPHRONS UNDERGOCHANGES TO COMPENSATE FOR
DAMAGED NEPHRONS
DECREASE RENAL PERFUSIONDECREASE BLOOD FLOW
GLOMERULI AND TUBULES ARESCARRED ANS BRANCHES OF RA
THICKENS
INCREASE PERIPHERAL RESISTANCE/INCREASE PRESSURE IN THE BLOOD
VESSELS
INTOLERANC
E AND EXHAUSTION OFREMAINING NEPHRONS
IMPAIRED FUNCTION OF KIDNEY
UREMIA (CHRONIC RENAL FAILURE)
HYPERTROPHY OF NEPHRONS
HYPERTENSION
INCREASE OF BLOOD PRESSURE
MALFUNCTION OF RAAS PROTEINURIA
DECREASE PROTEIN IN BLOOD
PLEURAL EFFUSION
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XV. LABORATORY RESULT February 1, 2010
Name: Patient
Constituent Rationale Conventional SI unit
Result Normalvalue Result Normal value
ALT/ SGPT Studies are based
on release of
enzymes from
damage liver cells.
These are elevated
in liver damage.
10.9 u/l 10-50u/l 10.9u/l 10.9u/l
AST/ SGOT 9.5 u/l 0-38u/l 9.5u/l 0-38u/l
Creatinine It is the acurate test
for kidney diseases.
17.58mg/dl 0.5-1.2m/dl 1.544
mmol/L
44-
106mmol/L
Glucose ( FBS) To know the glucose
level in the blood
93.5mg/dl 74-
106mg/dl
5.1mmol/L 4.11-
5.9mmol/L
Total protein To determine if the
patient experiencing
any alteration that
leads to liver
diseases.
6.2 g/dl 6.4-8.3g/dl 62g/L 64-83g/L
Albumin To diagnose any
cirrhosis,chronic
hepatitis,edema and
ascites.
3.6g/dl 3.4-4.8g/dl 36g/L 34-48g/L
Globulin To diagnose the
presence of any
liver diseases.
2.6g/dl 3.0-3.5 g/dl 26 g/L 30-35 g/L
A/G ratio To determine
chronic liver disease
1.4 g/dl 1.1- 1.8 g/dl 1.4 g/L 1.1-1.8 g/L
Potassium To know if the
patient is prone to
edema.
132.2 mg/dl 3.4-4.0
mg/dl
132.2
mmol/L
3.4-4.0
mmol/L
Chloride To maintain acid
base balance.
7.22 mg/dl 92-102
mg/dl
7.22
mmol/L
92-102
mmol/L
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XVII.EVALUATION
In doing this study, the researcher understand much better what is Chronic
Kidney Disease (CKD).It enhances the knowledge that we should have regarding the
various drugs that are related to treat the disease.
The data that was indicated in this study was obtained by having research,
conducting interview and performing physical assessment. The patients chart was also
used for the other information needed. During the interview the interviewee established
therapeutic communication and took the chance to conduct a health teaching to the
patient as well as to his significant others. The researcher hope that the health teaching
rendered can help the patient and his significant others in the situation that they are
going through. Most of all, the researcher performed the appropriate nursingmanagement to promote patients high optimum level of functioning regardless of
patient condition.
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City of Manila
UNIVERSIDAD DE MANILA
(Formerly City College of Manila)
A. Villegas St. Mehan Garden, Ermita, Manila
In partial fulfillment of the requirement in
Related Learning Experience
Gat Andres Bonifacio Memorial Medical Center Medicine Ward
A Case Study on
CHRONIC KIDNEY DISEASE
Submitted to:
Ms. Sandra Loberiano, RN(Clinical Instructor)
Submitted by:
Glazel JulianJona Lamson
Marlyn LindayaoMelody Lucmayon
Delio ManaoisChristina Marcial
Karissa Claudine MazoMichelle Morales
Jason NuguidAnne Monique Ongjoco
Eleeh Lour PedrazaMichael Stephen Pile
GROUP 3 Nr-31