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8/20/2019 Chronic Kidney Disease Secondary to DM Nephropathy
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I. INTRODUCTION
Chronic kidney disease (CKD), also known as Chronic Renal Failure, is a progressive loss
of renal function over a period of months or years. he symptoms of a worsening kidney
function are unspecific, and might include feeling generally unwell and e!periencing a reduced
appetite. "ften, chronic kidney disease is diagnosed as a result of screening of people known to
#e at risk of kidney pro#lems, such as those with high #lood pressure or dia#etes and those with
a #lood relative with chronic kidney disease. Chronic kidney disease may also #e identified when
it cardiovascular disease, anemia or pericarditis.
he kidneys fail in an organi$ed fashion. %rogression toward &'RD usually starts with a
gradual decrease in renal function of * to +*.
ere are the stages of CKD.
Stage 1: Diminished Renal Reserve
Renal function is reduced, #ut no accumulation of meta#olic wastes occurs.
he healthier kidney compensates for the diseased kidney.
-#ility to concentrate urine is decreased, resulting in nocturia and polyuria.
- / hour urine collection for creatinine clearance is necessary to detect that the renal reserve
is less than normal.
Stage 2: Renal Insufficiency
0eta#olic wastes #egin to accumulate in the #lood #ecause the unaffected nephrons can no
longer compensate.
Responsiveness to diuretics is deceased, resulting in oliguria and edema.
he degree of insufficiency is determined #y the decreasing 1FR and is classified as mild,
moderate and severe.
reatment is medical.
Stage : !nd Stage Renal Disease
&!cessive amounts of meta#olic wastes such as urea and creatinine accumulate in the #lood.
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he kidneys are una#le to maintain homeostasis.
reatment is #y dialysis or other renal replacement therapy.
-ccording to research the prognosis of patients with CKD is guarded as epidemiological
data has shown that all causes mortality increases as kidney function decreases. he Centers for
Disease Control and %revention found that CKD affected an estimated 23.4* of adults aged
years and older during + to 22.
"ge:
-ge of 5 3+ years old.
#ender:
Chronic Kidney Disease is more common in men than in women.
#enetics:
- family history of renal disease.
Race:
Chronic Kidney Disease is a ma6or concern in 7ative -merican, -frican -merican and
ispanic mostly due to increased prevalence of hypertension.
8* of &'RD cases in -frican -mericans can #e attri#uted to high #lood pressure
C$mm$n Diseases:
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eart Failure, ypertension, Dia#etes 0ellitus and 1lomerulonephritis.
%UR%OS! "ND O&'!CTI(!S
1. #eneral O)*ectives
-ims to #roaden the knowledge, skills and attitude of the student nurses and the mem#ers of
the health team a#out the disease.
o #e a#le to respond, intervene, and render accurate nursing care to clients with Chronic
Kidney Disease
2. S+ecific O)*ectives
9nderstand the pathophysiology of Chronic Kidney Disease and determine the ma6or disease
manifestations, risk factors and etiology
Formulate an effective nursing care plan and implement nursing interventions appropriately
#ased on the prioriti$ed health needs of the client maintaining sound communication with the
patient and mem#ers of the health team.
%rovide #etter nursing care and health teachings to their client through the utili$ation of the
nursing process.
SI#NI,IC"NC! "ND 'USTI,IC"TION
he group chose this case #ecause more clinical skills will #e developed #y e!periencing
the clinical management of the disease condition and it will enhance one:s knowledge in
implementing proper nursing intervention for the patient towards recovery. -nd it is the first time
the group has encountered this type of case.
SCO%! "ND -IIT"TIONS
he scope of the Chronic Kidney Disease encompasses the anatomy, physiology and
pathophysiology. he actual interaction with the client was done last ;uly /, +, 3 and ,
2/ on our hospital duty 3
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reading the chart, interviewing the client as well as with the help of the staff nurses assigned to
the client.
&"C/#ROUND O, T0! STUD
he site of the study was done at "spital ng 0aynila 0edical Center, 0edicine =ard. he
different diagnostic procedures and operation were done in the same institution.
he group chose this case study to know the disease, its clinical manifestations, risk
factors, pathophysiology and diagnostic procedure for the disease, to identify different medical
and nursing care management for patient with Chronic Kidney Disease.
II. %R!S!NT"TION O, T0! C-I!NT
- case of 1.>. /? years old from medicine ward female. - Filipina came from the ethnicity
of @isaya. - Roman Catholic, igh 'chool 1raduate, ousewife, from District AA ondo, 0anila.
%atient was admitted for the second time at "spital ng 0aynila 0edical Center last ;uly
, 2/ at e!actly 4am. 'he was conscious and coherent and am#ulatory accompanied #y her
hus#and. 4 hours prior to admission the patient had an onset of difficulty of #reathing. %atient
1.> was admitted with a chief complaint of difficulty of #reathing.
he patient is known Dia#etic for years. 'he had no accident or in6uries in the past and
no food or drug allergies. >ast Fe#ruary 2, she was diagnosed with %@ at "spital ng
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0aynila 0edical Center. er maintenance medications are 0etformin +mg "D per "rem and
-mlodipine +mg "D per "rem.
%atient has a family history of ypertension on paternal side and no known history on
maternal side. er father died due to hypertension and her mother died due to la#or on her. er
youngest #rother had ypertension and her younger sister died on dengue.
COURS! IN T0! "RD
Date D$ct$r3s Order Interventi$ns
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;uly , 2/
ipid %rofile, 7a, K,
CR, and 2 > &C1.
0ed.
2. 0etformin +mgta# @AD
.Furosemide /mg AE 4
.-mlodipine +mgta# "D
/. 7aC" 3+mgta# AD
+. FeGF- "D
Refer for -nesthesia 'urgery
for A; catheteri$ation
Refer to 7ephro
Refer accordingly
Consent signed and secure
"riented client and family to
ward policies
Anitial E' taken
&!plained diet to the client and
family
0aintained diet as ordered
For referral to 7ephrology
service
Kept safe and comforta#le
'een at times
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;uly /, 2/
hursday
2
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"mepra$ole /mg AE now
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;uly 4, 2/
0onday
+
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;uly ?, 2/
uesday
?
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-"&OR"TORI!S "ND DI"#NOSTICS T!ST
-a) !4am N$rmal values "ctual findings "nalysis 5 Inter+retati$n
@97 .? L 8.+ mmol> /.2 mmol> &levated levels< Renal
disease, reduced renal
#lood flow (caused #y
dehydration), urinary tract
o#struction, and increased
protein cata#olism (such as
#urns)
Creatinine .+2 mgdl 2+ mgdl &levated levels generally
indicate renal disease that
has seriously damaged
+* or more of the
nephrons.
F@' /.22 L +.? mmol> +. mmol> 7ormal result
%otassium .+ L +. mmol> +. mmol> 7ormal result
riglyceride ./ L .+mmo> ./mmo> - mild to moderate
increase in serum
triglyceride levels indicates
#iliary o#struction,
dia#etes mellitus, nephrotic
syndrome or over
consumption of alcohol.
'odium 2/ 2/+ mmol> 24mmol> 7ormal result
Chloride 224 mmol> 22 mmol> -n increased in chloride
levels may #e evident in
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severe dehydration and
complete renal shutdown.
"->
C">&'&R">
.4 L +.2 mmol> /.34 mmol> 7ormal result
D> .48 L 2.?/ mmol> 2.4 mmol> 7ormal result
>D> 2. L .+ mmol> .+ mmol> 7ormal result
=@C /.3 2. 2e?> 3.3 2e?> 7ormal result
7eutrophils .3 L .8 2e?> .+8 2e?> - small num#er of slightly
immature neutrophils,
known as #and cells, are
present in peripheral #lood.
>ymphocytes . L ./ 2e?> .8 2e?> 7ormal result
0onocytes .8 2e?> ./ 2e?> 7ormal result
1@ 2 24 2e?> 4.2e?> >ow hemoglo#in level may
indicate anemia, recent
hemorrhage, or fluid
retention causing
hemodilution.
C .8 .+/gm> .gm> 7ormal result
%latelet 2+ L /+ 2e?> 4.2e?> 7ormal result
#$rd$n3s ,uncti$nal 0ealth %attern
%"TT!RNS O,
0!"-T0
%RIOR TO
0OS%IT"-I6"TION
DURIN#
0OS%IT"-I6"TION
"nalysis 5
Inter+retati$n
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I. 0ealth
+erce+ti$n and
health management
+attern
B%atient 1.> life:s #efore
confinement consults
medical doctor during
her sickness and doesn:t
use any illegal drugs and
doesn:t maintain good
health always eat
whatever she likes
especially salty and
sweet foods.
B During hospitali$ation
she maintains health #y
avoiding salty, sweet
and fatty foods.
• ealth perception
changes as the
situation changes.
Knowledge a#out
health condition
e!pands.
• %atient perceives
her health condition
as a hindrance
compared to the
previous illness she
e!perienced.
II. Nutriti$n and
meta)$lism
management
B %atient 1.> life:s
#efore confinement she
eats whatever she likes.
'he loves to eat salty,
sweet and fatty foods and
ate times a day with
snack, had a good
appetite and drinks 4
glass of water.
BDuring hospitali$ation
her diet has #een
controlled and limit
fluid intake ml per
day as ordered.
• aving a nutritional
diet is necessary for
every individual to
live. Food is the
main source energy
which contri#utes to
meet physiologic
function.
• &at soft food. 0ust
receive adeJuatenutrition while
recovering.
III. !liminati$n
+attern
B @efore #eing
hospitali$ed, she voids 3
times a day and defecates
twice a day.
B During hospitali$ation
she does not void.
• &limination pattern
is necessary to
flushed out the
#acteria inside the
#ody moreover it is
a site of having
system that
functions well.
• 9na#le to defecate
during
hospitali$ation.
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I(. "ctivities and
e4ercise +attern
B -ccording to her, she
always does the
household chores, and
had some minutes:
walk around their
community. as selfcare
hygiene and grooming,
sitting #y her own,
getting up from #ed and
changing clothes.
B During hospitali$ation
activities of daily living
#ecome more limited.
'ome activities reJuire
assistance or
supervision.
• he a#ility to move
provides mental
wellness and the
effectiveness of #ody
functioning depend
largely on their
mo#ility status
which could
influences the self
esteem and #ody
image.
• er condition affects
mo#ility and gait
wherein there are
already limitations in performing
activities.
(. C$gnitive
+erce+tual +attern
Bhere are no changes in
her sensory a#ilityM she is
ver#ally and physically
responsive.
Bhere are no changes
in her sensory a#ilityM
she is ver#ally and
physically responsive.
• umor is
increasingly valued
as #oth an
interpersonal skill
for nurse and a
healing strategy for
patients.• here are no changes
in her sensory
a#ilityM she is
ver#ally responsive
to physical stimuli.
'he has a competent
learning pattern.
(I. Slee+ and rest
+attern
B %atient 1.> life:s
#efore confinement she
sleeps 4 hours a day and
has no difficulty in
sleeping, does not wake
up in the middle of the
night.
B During hospitali$ation
she is always at her #ed
and taking a nap
whenever possi#le.
• Rest and sleep are
essential for health.
Rest implies
calmness, rela!ation
without emotional
stress, and freedom
from an!iety. At
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restores the energy
that has #een used,
which allows the
person to resume
optimal functioning.
• 9pon
hospitali$ation the
num#er of her sleep
was lessen due to the
environmental
factors arising in the
hospital.
(II. Self7+erce+ti$n
and self7c$nce+t
+attern
B'he descri#ed herself as
cheerful, talkative and
not easily gets angry.
B 9pon hospitali$ation
she:s still cheerful and
gets worried a#out
simple things.
• 'elfconcept is how
a person feels a#out
himself and
perceives the
physical health and
handle situations.
'uch attitude can
affect health
practices, responses
to stress and illness
and the time when
treatment is sought.
• %atient shows self
confident.
(III. R$le and
relati$nshi+ +attern
B'he has 2 daughter and
si#lings. Family
worries on her
hospitali$ation.
B'he has 2 daughter and
si#lings. Family
worries on her
hospitali$ation.
• Relationship with
other family
mem#ers #oosts her
selfesteem and self
confidence allowing
her to cope with her
pro#lem. 0oreover,
a person having
health pro#lems
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needs selfesteem
and selfconfidence
in order for her to
handle the situation
of the pro#lem.
I8. Se4uality and
re+r$ductive
+attern
B0enarche started at 2years old. as gravida 2,
para 2, preterm ,
a#ortion , childrenliving 2.
• 'e!uality is a crucial
part of personNs
identity. 'e!
determines who we
are to our emotional
well#eing and to the
Juality of our lives.
•
7o se!ualintercourse had #een
noted #ecause she
was a widowed.
8. C$+ing stress
and t$lerance
+attern
B'he was a#le to cope
with her stress #y takingcare of her grandchild
and she also manages her
stress #y doing
household chores.
BDuring hospitali$ation
she was playing cards,
and listening to radio
and chatting to her
niece.
• Coping strategies
vary from
individuals and are
often related to
individuals perception of a
stressful events
strategy use #y the
client was emotion
focus and a very
typical coping
strategies used #y the
patient.
8I. (alues and)elief +attern
B'he has a strong faith in
1od and prays often.
BDuring hospitali$ationher faith in 1od #ecomes stronger. 'he
always prays for her fast
recovery.
• Ealues are learn
through o#servation
and e!perience as a
result they are
heavily influence #y
a person, socio
cultural environment
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that is #y societal
tradition, ethnic, and
religious group.
III. "N"-SIS "ND INT!R%R!T"TION
An our study the client was diagnosed with chronic kidney disease, secondary to dia#etes
mellitus nephropathy. 7ephropathy is pathologic change in the kidney that reduces kidney
function and leads to renal failure. Chronic high #lood glucose levels causes hypertension in
kidney #lood vessels and e!cess kidney perfusion. he increased pressure damages the kidney in
many ways. he #lood vessels #ecome leakier, especially in the glomerulus. his leakiness
allows the filtration of larger particles (including al#umin O other proteins) which then form
deposits in the kidney tissue O #lood vessels. Deposits narrow the vessels, decreasing kidney
o!ygenation O leading to kidney cell hypo!ia O cell death. hese processes worsen over time.
@lood vessels in the glomerulus #ecome scarred O una#le to filter urine from the #lood, leading
to renal failure.
Diagn$sis
"ltered &reathing %attern
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9pon admission patient reported onset of difficulty of #reathing. -s per emergency room
record, respiratory rate is 3 #reaths per minute. %atient had flaring nostrils and could not
tolerate flat lying position. he condition is pro#a#ly due to lung congestion which resulted from
altered glomerular filtration that cause sodium retention that further holds fluid and congest the
lungs so the lungs cannot e!pand as usual. %atient e!perienced feeling of heaviness.
•Ris9 f$r infecti$n and "cute +ain
%atient is schedule for A; insertion. -t /
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compensate completely for the nonfunctioning nephron. >evel of @97, serum creatinine, uric
acid, and phosphorus are elevated in proportion to the amount of nephrons lost. "ver time, most
clients progress to &'RD. &!cessive amount of urea and creatinine #uild up in the #lood, and the
kidneys cannot maintain homeostasis. 'evere fluid, electrolyte, and acid#ase #alances occurs.
=ithout renal replacement therapy, fatal complications are likely.
anifestati$ns:
Chronic kidney disease initially without specific symptoms and is generally only detected
as increase in serum creatinine or protein in the urine. he client may also e!perience nausea,
vomiting, loss of appetite, fatigue and weakness, sleep pro#lems, changes in urine output,
swelling of feet and ankles, chest pain, shortness of #reath and high #lood pressure. -lso patient
with chronic kidney disease suffer from accelerated atherosclerosis and are more likely to
develop cardiovascular disease than the general population.
!ti$l$gy:
hree main causes of CKD are Dia#etes 0ellitus, ypertension and 1lomerulonephritis.
Ris9 fact$rs:
Race< 7ative -merican, -frican -merican, ispanic. -ge< 5 3+ years old. 1enetics<
Family history of renal disease. Certain diseases like eart Failure, ypertension, D0 and
1lumerulonephritis.
O)*ective 2: -naly$e, assist and interpret the different diagnostic and la#oratory procedures, its
purpose and relationship to client:s disease condition.
http://en.wikipedia.org/wiki/Atherosclerosishttp://en.wikipedia.org/wiki/Cardiovascular_diseasehttp://en.wikipedia.org/wiki/Cardiovascular_diseasehttp://en.wikipedia.org/wiki/Atherosclerosis
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• &UN
&levated levels< renal disease, reduced renal #lood flow (caused #y dehydration), urinary tract
o#struction, and increased protein cata#olism (such as #urns)
• TRI#-C!RID!.
P0arkedly increased levels without an identifia#le cause reflect congenital hyperlipoproteinemia
and necessitate lipoprotein phenotyping to confirm the diagnosis.
• C0-ORID!.
Decreased levels may result from e!cessive diaphoresis, heart failure, hypochloremic meta#olic
alkalosis, or prolonged vomiting gastric suctioning.
O)*ective : %rovide #etter nursing care and health teachings to their client through the
utili$ation of the nursing process.
%r$)lem: -ltered #reathing pattern related to decreased lung e!pansion as evidenced #y
difficulty of #reathing.
Anterventions<
• %osition with proper #ody alignment for optimal #reathing pattern.
• %rovide rela!ation training as appropriate
• -dminister o!ygen at lowest concentration.
• &ncourage adeJuate rest period #etween activities.
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%r$)lem< -ltered comfort related to pain as evidenced #y previous A; insertion
Anterventions<
• %rovide rest period to facilitate comfort, sleep O rela!ation.
• -pply warm compress
• &ncourage diversional activities• %rovide calm O Juiet environment
• Anstruct use of rela!ation e!ercise such as focused #reathing.
%r$)lem: &!cess fluid volume related to end stage renal failure
Anterventions <
• 0easure AO" every / hours, and notify physician if im#alances are significant
• 0aintain patient:s dietary restrictions, including fluid restrictions. %ost signs and remove
water pitcher from room.• 0onitor vital signs every hours and %R7. 7otify physician for significant changes.
• "#serve patient and assess for degree of edema to e!tremities and periphery
• 0onitor la# work for @97, Creatinine, and electrolyte levels
%r$)lem< Risk for infection related to insufficient knowledge to avoid e!posure to pathogen
Anterventions <
• "#serve for locali$ed sign of infection at insertion sites of invasive line, sutures, and
surgical wounds.
• -ssess and document skin conditions around insertions of pins, wires and tongs noting
inflammation and drainage.
• 7oting signs and symptoms of sepsis< fever, chills, diaphoresis, altered level of
consciousness, positive #lood culture.
• Anstruct client in techniJues to protect the integrity of skin, care for lesions and
prevention of spread of infection
%r$)lem: 7oncompliance to difficulty changing #ehaviour.
Anterventions<
• Develop therapeutic nurseclient relationship.
• &ncourage client to maintain selfcare, providing for assistance when necessary.
• %rovide for continuity of care in and out of the hospital care setting, including long
range plans.
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• %rovide information and help client to know where and how to find it on her own.
• 1ive information in managea#le amounts using ver#al, written, and auto visual modes at
level of client:s a#ility.
C$nclusi$n
'ince the patient suffered from Chronic kidney disease, the related factors that promoted
meeting of needs is to prevent or slow further damage to the kidneys, and monitor conditions
such as dia#etes or high #lood pressure that usually causes kidney disease, so it is important to
identify and manage the condition that is causing the kidney disease. At is also important to
prevent diseases and avoid situations that can cause kidney damage or make it worst.
Competencies of nurses that promoted the meeting of needs include ensuring safety and
privacy, alleviating discomfort, monitoring vital signs on time and instructing the client to follow
the diet that is recommended #y the physician. 'trict #lood pressure control is a high priority in
the care of the patient with chronic kidney disease. For the reasons mentioned a#ove, -C&
inhi#itors are commonly used as the initial medications to achieve #lood pressure controlM
however, often a multidrug regimen is needed. Commonly, diuretics are needed for patients with
chronic kidney disease #ecause of the hypertensive effect of volume overload. Regardless of the
cause of CKD, tight glycemic control should #e achieved for all dia#etic patients. -dministering
insulin is recommended to control further complications and increase in #lood glucose level.
• -ltered #reathing pattern related to decreased lung e!pansion
- his pro#lem is solved as evidenced #y respiratory rate of 2? #reaths per
minute.
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• &!cess fluid volume related to end stage renal failure
- his pro#lem is still unresolved as evidenced #y #ipedal edema.
• -ltered comfort related to pain
- his pro#lem is partially resolved as evidenced #y reduced pain as ver#ali$ed
#y the patient. %'< 2
• Risk for Anfection related to insufficient knowledge to avoid e!posure to
pathogens- his pro#lem is resolved. %atient ver#ali$ed understanding of ways to prevent
infection.
• 7onCompliance related to difficulty changing lifestyle particularly diet and
medication regimen.- his pro#lem is resolved. %atient ver#ali$ed understanding of disease
condition and importance of following treatment regimen.
Rec$mmendati$n
-fter conducting the case study and finding the client:s response to interventions, we recommend
the following<
'tudent nurses should properly assess the client:s level of understanding of her disease
condition, and provide appropriate nursing interventions and other health care follow ups. 'tudent nurses should provide appropriate management #ase on the physical assessment,
1ordon:s functional pattern and la#oratory and diagnostics findings.