CKD - Case Pres

7/28/2019 CKD - Case Pres

http://slidepdf.com/reader/full/ckd-case-pres 1/29

Southern Luzon State University

College of Allied Medicine

Lucban, Quezon

Pyomyositis

A CASE STUDY PRESENTED TO:

Mrs. Dulce

(clinical instructor)

In Partial Fulfillment of the Requirements in the Subject:

NCM 104: Related Learning Experience

Submitted by:

Rhealyca E. Mendoza

(Group 1)

October 12, 2009



I. LEARNING OBJECTIVES

A. General Objectives

After establishing a nurse-patient interaction, providing care to the client and by a

thorough assessment and careful study about the patient’s condition, student will be able to

gain knowledge, develop skills and enhance attitude to determine appropriate care and

management in patients having Chronic Kidney Disease.

B. Specific Objectives

Given the opportunity to conduct study and render care to the patient with chronic kidney

disease, the student will be able to:

1. Define and Understand what Chronic Kidney Disease is.

2. Distinguishes its clinical manifestations, epidemiology and predisposing factors.

3. Present anatomy and physiology.

4. Outline the pathophysiology of the disease condition.

5. Establish a good and effective nurse-patient interaction.

6. Determine health status of the patient through:

a. General Data

b. Physical Assessment

c. Past and Present History of the Illness

d. Family Health History

e. Personal and Social History

7. Analyzing the laboratory examination done and correlate it to the present

condition of the patient. Determine the appropriate nursing care that should be

provided to the client:

a. Be familiar to the different medical procedures done to the patient.

b. Understands the different drugs that the client is taking and determine how it

will benefit the client as well as the possible adverse effects it may give.

c. Evaluate the effectiveness of NCP and medical treatment

8. Create a good and therapeutic nurse-patient relationship.

9. Teach the client’s relatives as well as other people on how to minimize the risk of

developing chronic kidney disease.



II. INTRODUCTION

Chronic kidney disease is when one suffers from gradual and usually permanent loss of

kidney function over time. This happens gradually over time, usually months to years. Chronic

kidney disease is divided into five stages of increasing severity. Stage 5 chronic kidney failure is

also referred to as end-stage renal disease, wherein there is total or near-total loss of kidney

function and patients need dialysis or transplantation to stay alive. The term "renal" refers to the

kidney, so another name for kidney failure is "renal failure." Mild kidney disease is often called

renal insufficiency.

1,212,306 adult Filipinos have CKD (NNHeS 2003-2004 Renal Report), a figure that

is remarkably noticeable because of its increase and continuously rise as years passes by. The

common causes of the disease are diabetes and high blood pressure which are life-style related.

Most kidney diseases attack the nephrons, causing them to lose their filtering capacity. Damage

to the nephrons may happen quickly, often as the result of injury or poisoning. But most kidney

diseases destroy the nephrons slowly and silently. Only after years or even decades will the

damage become apparent. Most kidney diseases attack both kidneys simultaneously.

Chronic kidney disease is identified by a blood test for creatinine. Higher levels of

creatinine indicate a falling glomerular filtration rate and as a result a decreased capability of the

kidneys to excrete waste products. Creatinine levels may be normal in the early stages of CKD,and the condition is discovered if urinalysis shows that the kidney is allowing the loss of protein

or red blood cells into the urine. To fully investigate the underlying cause of kidney damage,

various forms of medical imaging, blood tests and often renal biopsy are employed to find out if

there is a reversible cause for the kidney malfunction.

OVERVIEW OF THE DISEASE

A. DEFINITION

Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss

of renal function over a period of months or years. The symptoms of worsening kidney function

are unspecific, and might include feeling generally unwell and experiencing a reduced appetite.

Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk

of kidney problems, such as those with high blood pressure or diabetes and those with a blood

relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads

to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis.



B. SYMPTOMS

The kidneys are remarkable in their ability to compensate for problems in their function.

That is why chronic kidney disease may progress without symptoms for a long time until only

very minimal kidney function is left.

The kidneys perform so many functions for the body; kidney disease can affect the body

in a large number of different ways. Symptoms vary greatly. Several different body systems may

be affected. Most patients have no decrease in urine output even with very advanced chronic

kidney disease.

• Fatigue and weakness (from anemia or accumulation of waste products in the body)

• Loss of appetite, nausea and vomiting

• Need to urinate frequently, especially at night

• Swelling of the legs and puffiness around the eyes (fluid retention)

• Itching, easy bruising, and pale skin (from anemia)

• Headaches, numbness in the feet or hands (peripheral neuropathy), disturbed sleep,

altered mental status (encephalopathy from the accumulation of waste products or uremic

poisons), and restless legs syndrome

• High blood pressure, chest pain due to pericarditis (inflammation around the heart)

• Shortness of breath from fluid in lungs

• Bleeding (poor blood clotting)

• Bone pain and fractures

• Decreased sexual interest and erectile dysfunction

C. CAUSES

Although chronic kidney disease sometimes results from primary diseases of the kidneys

themselves, the major causes are diabetes and high blood pressure.

• Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy.

• High blood pressure (hypertension), if not controlled, can damage the kidneys over time.

• Glomerulonephritis is the inflammation and damage of the filtration system of the

kidneys and can cause kidney failure. Postinfectious conditions and lupus are among the

many causes of glomerulonephritis.

• Polycystic kidney disease is an example of a hereditary cause of chronic kidney disease

wherein both kidneys have multiple cysts.



• Use of analgesics such as acetaminophen and ibuprofen regularly over long durations of

time can cause analgesic nephropathy. Certain other medications can also damage the

kidneys.

• Clogging and hardening of the arteries (atherosclerosis) leading to the kidneys causes a

condition called ischemic nephropathy.

• Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowings),

or cancers may also cause kidney disease.

• Other causes of chronic kidney disease include HIV infection, sickle cell disease, heroine

abuse, amyloidosis, kidney stones, chronic kidney infections, and certain cancers.

D. STAGES

All individuals with a Glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for 3

months are classified as having chronic kidney disease, irrespective of the presence or absence of

kidney damage. The rationale for including these individuals is that reduction in kidney function

to this level or lower represents loss of half or more of the adult level of normal kidney function,

which may be associated with a number of complications.

All individuals with kidney damage are classified as having chronic kidney disease,

irrespective of the level of GFR. The rationale for including individuals with GFR 60

mL/min/1.73 m2 is that GFR may be sustained at normal or increased levels despite substantial

kidney damage and that patients with kidney damage are at increased risk of the two major

outcomes of chronic kidney disease: loss of kidney function and development of cardiovascular

disease.

Stages of Chronic Kidney Disease



Stage Description

GFR (mL per minute

per 1.73 m2) Metabolic consequences

- At increased risk Higher than 60 (with

risk factors for chronic

kidney disease)

-

1 Kidney damage (early) with

normal or elevated GFR

90 or higher -

2 Kidney damage with mildly

decreased GFR (early renal

insufficiency)

60 to 89* Parathyroid hormone level begins to

rise (GFR of 60 to 80).

3 Moderately decreased GFR

(moderate kidney failure)

30 to 59 Calcium absorption decreases (GFR

below 50).

Lipoprotein activity declines.

Malnutrition develops.There is onset of left ventricular

hypertrophy and/or anemia

(erythropoietin deficiency).

4 Severely decreased GFR

(pre-end-stage kidney

disease)

15 to 29 Triglyceride concentration begins to

rise.

Hyperphosphatemia or metabolic

acidosis develops.

There is a tendency toward

hyperkalemia.

5 Kidney failure < 15 (or dialysis) Azotemia develops.

E. RISK FACTORS



• Diabetes mellitus type 1 or 2

It is a chronic disease associated with abnormally high levels of the sugar glucose

in the blood. Diabetes is due inadequate production of insulin or inadequate sensitivity of

cells to the action of insulin.

• High blood pressure

It is a repeatedly elevated blood pressure exceeding 140 over 90 mmHg -- a

systolic pressure above 140 with a diastolic pressure above 90.

• High cholesterol

It is the fatty deposits in your blood vessels. Eventually, these deposits make it

difficult for enough blood to flow through your arteries.

• Heart disease

It is any disorder that affects the heart. Heart disease is synonymous with cardiac

disease but not with cardiovascular disease which is any disease of the heart or blood

vessels

• Liver disease

Liver disease refers to any disorder of the liver. The liver is a large organ in the

upper right abdomen that aids in digestion and removes waste products from the blood.

• Kidney disease

Kidney disease is any disease or disorder that affects the function of the kidneys

which affects the rate of filtration of the nephrons.

• Amyloidosis

It is any disorder that results from the abnormal deposition of a particular protein,

called amyloid, in various tissues of the body. Amyloid protein can be deposited in a

localized area, and not be harmful, or in can cause serious changes in virtually any organ

of the body.

• Sickle cell disease

It is agenetic blood disease due to the presence of an abnormal form of

hemoglobin, namely hemoglobin S. Hemoglobin is the molecule in red blood cells that

transports oxygen from the lungs to the farthest reaches of the body.

• Systemic Lupus erythematosus

It is a chronic inflammatory condition caused by an autoimmune disease. An

autoimmune disease occurs when the body's tissues are attacked by its own immune

system. Patients with lupus have unusual antibodies in their blood that are targeted

against their own body tissues.

• Vascular diseases such as arteritis, vasculitis, or fibromuscular dysplasia



Arteritis is inflammation of the walls of arteries, usually as a result of infection or

auto-immune response.

Vasculitis is a general term for a group of diseases that feature inflammation of

the blood vessels. Each of these diseases is defined by characteristic distributions of

blood vessel involvement, patterns of organ involvement, and laboratory test

abnormalities.

Fibromuscular dysplasia (FMD) is a condition in which at least one of your

arteries has an abnormal cluster of cells growing in the artery wall. This cluster causes the

artery to narrow, which can cause damage to the organs that receive blood through the

narrowed artery.

• Vesicoureteral reflux

It refers to a condition in which urine flows from the bladder, back up the ureter,

and back into the kidneys.

• Problems of the joints or muscles that require regular use of anti-inflammatory

medications

• Family history of kidney disease

F. TESTS AND DIAGNOSIS

Chronic kidney disease usually causes no symptoms in its early stages. Only lab tests can

detect any developing problems. Anyone at increased risk for chronic kidney disease should be

routinely tested for development of this disease.

URINE TESTS

•

UrinalysisAnalysis of the urine affords enormous insight into the function of the

kidneys. The first step in urinalysis is doing a dipstick test. The dipstick has

reagents that check the urine for the presence of various normal and abnormal

constituents including protein. Then, the urine is examined under a microscope to

look for red and white blood cells, and the presence of casts and crystals.

Only minimal quantities of albumin (protein) are present in urine

normally. A positive result on a dipstick test for protein is abnormal. More

sensitive than a dipstick test for protein is a laboratory estimation of the urine

albumin (protein) and creatinine in the urine.

• Twenty-four-hour urine tests



This test requires you to collect all of your urine for 24 consecutive hours.

The urine may be analyzed for protein and waste products (urea, nitrogen, and

creatinine). The presence of protein in the urine indicates kidney damage. The

amount of creatinine and urea excreted in the urine can be used to calculate the

level of kidney function and the glomerular filtration rate (GFR).

• Glomerular filtration rate (GFR)

The GFR is a standard means of expressing overall kidney function. As

kidney disease progresses, GFR falls. The normal GFR is about 100-140 mL/min

in men and 85-115 mL/min in women. It decreases in most people with age. The

GFR may be calculated from the amount of waste products in the 24-hour urine or

by using special markers administered intravenously. Patients are divided into

five stages of chronic kidney disease based on their GFR.

BLOOD TESTS

• Creatinine and urea (BUN) in the blood

Blood urea nitrogen and serum creatinine are the most commonly used

blood tests to screen for, and monitor renal disease. Creatinine is a breakdown

product of normal muscle breakdown. Urea is the waste product of breakdown of

protein. The level of these substances rises in the blood as kidney function

worsens.

• Estimated GFR (eGFR)

This may calculate an estimated GFR using the information from your

blood work. It is important to be aware of your estimated GFR and stage of

chronic kidney disease. Physicians uses your stage of kidney disease to

recommend additional testing and suggestions on management.

•Electrolyte levels and acid-base balance

Kidney dysfunction causes imbalances in electrolytes, especially

potassium, phosphorus, and calcium. High potassium (hyperkalemia) is a

particular concern. The acid-base balance of the blood is usually disrupted as

well.

Decreased production of the active form of vitamin D can cause low levels

of calcium in the blood. Inability to excrete phosphorus by failing kidneys causes

its levels in the blood to rise. Testicular or ovarian hormone levels may also be

abnormal.

• Blood cell counts

Kidney disease disrupts blood cell production and shortens the survival of

red cells, the red blood cell count and hemoglobin may be low (anemia). Some



patients may also have iron deficiency due to blood loss in their gastrointestinal

system.

OTHER TESTS

• Ultrasound

Ultrasound is often used in the diagnosis of kidney disease. An ultrasound

is a noninvasive type of test. In general, kidneys are shrunken in size in chronic

kidney disease, although they may be normal or even large in size in cases caused

by adult polycystic kidney disease, diabetic nephropathy, and amyloidosis.

Ultrasound may also be used to diagnose the presence of urinary obstruction,

kidney stones and also to assess the blood flow into the kidneys.

• Biopsy

A sample of the kidney tissue is sometimes required in cases in which the

cause of the kidney disease is unclear. Usually, a biopsy can be collected with

local anesthesia only by introducing a needle through the skin into the kidney.

G. COMPLICATIONS

• Hypertension

Hypertension, or high blood pressure, is present in 80 to 85 percent of people with

CKD. This is due to a number of factors, including changes in the levels of blood

pressure hormones secreted by the kidneys and the presence of extra fluid in the blood

vessels as the kidneys lose their ability to efficiently balance fluid levels. Treatment

begins with an ACE inhibitor.

• Volume overload

Patients with CKD often develop fluid overload, which can lead to hypertensionand edema. Treatment of volume overload often requires a low salt diet.

• Anemia

Patients with CKD are at risk for anemia, or low red blood cell counts. This is

largely due to reduced production of a substance called erythropoietin by the kidneys.

Erythropoietin stimulates the body to make red blood cells, the critical oxygen-carrying

cells in the blood. When anemia occurs, oxygen delivery to the tissues falls below

normal, which can lead to fatigue and other complications.

Selected patients can be treated with drugs that stimulate red blood cell

production. In some cases, iron supplements are also prescribed.

• High potassium (hyperkalemia)



Some patients with CKD develop a high blood potassium level, which can

interfere with normal cell function. Measures to prevent high potassium may also be

recommended, including a low potassium diet and avoiding medicines that raise

potassium levels.

• Acidosis

Patients with CKD can develop a condition known as acidosis, which means that

the blood is too acidic. Without treatment, acidosis can worsen other complications of

CKD, such as bone disease or loss of muscle mass in the body. Treatment usually

includes use of sodium bicarbonate.

• High phosphate (hyperphosphatemia)

If the phosphate balance is disturbed by CKD, bone regeneration is adversely

affected. Early in the course of CKD, the body begins to retain phosphate. As the disease

progresses and GFR declines significantly, high blood phosphate levels can develop. This

is usually treated with medicines that bind dietary phosphate in the gastrointestinal tract.

Dietary phosphate restrictions are also recommended.

• Bone disease

Progressive kidney dysfunction is associated with a number of abnormalities that

adversely affect bone. These include elevated phosphate and parathyroid hormone levels

and decreased calcium and vitamin D levels.

A person with CKD who develops bone disease or elevated phosphate is usually

treated with multiple medicines and supplements that attempt to correct some of these

abnormalities.

• Hyperlipidemia

Abnormal fat metabolism is common in patients with kidney disease. The most

common problem is an abnormally elevated blood triglyceride levels. High triglycerides

have been associated with an increased risk of coronary artery disease, which can lead toheart attack. The risk of death, particularly due to cardiovascular disease, is much higher

in people with CKD than the risk of eventually needing dialysis or kidney transplantation.

• Malnutrition

Malnutrition is common in people with advanced CKD because of loss of appetite

and decreased food intake, decreased absorption of food from the intestines, and acidosis.

The level of malnutrition can be determined by measuring a patient's weight and the level

of albumin in the blood; low albumin levels are one sign of malnutrition.

• Bleeding

An increased risk of bleeding develops in patients with very advanced or "end

stage" CKD as a result of impaired platelet function. Platelets are a critical component of

the blood clotting mechanism. No treatment is needed in patients without excessive



bleeding. Medicines may be given to counter the platelet dysfunction if there is excessive

bleeding, or if the patient needs to undergo surgery or an invasive medical procedure.

• Sexual function

Men and women with advanced CKD often have significant difficulties with

sexual and reproductive function. Over 50 percent of men with end-stage renal disease

have difficulties with erection and decreased sex drive. Women often have disturbances

in the menstrual cycle and fertility, usually leading to a stop in menstrual periods.

Decreased sex drive may also occur in women. Patients should discuss any changes in

sexual function with their healthcare provider because medications or other treatments

may be effective.

• Pregnancy

The risk that pregnancy will worsen kidney function, or that decreased kidney

function will interfere with pregnancy depends upon a number of factors. A woman with

mild to moderate CKD who is considering becoming pregnant should discuss the possible

risks with her nephrologist and obstetrical provider before trying to conceive.

Pregnancy is not recommended for women with end-stage kidney disease due to

the increased risk of miscarriage, premature delivery, worsened kidney function, and

preeclampsia. A woman who undergoes successful renal transplantation has a reduced

risk of these complications.

H. TREATMENT

• Protein restriction

Decreasing protein intake may slow the progression of chronic kidney disease. A

dietitian can help to determine the appropriate amount of protein for the patient.

•Salt restriction

Limit to 4-6 grams a day to avoid fluid retention and help control high blood

pressure.

• Fluid intake

Excessive water intake does not help prevent kidney disease. In fact doctors may

recommend restriction of water intake.

• Potassium restriction

This is necessary in advanced kidney disease because the kidneys are unable toremove potassium. High levels of potassium can cause abnormal heart rhythms.

Examples of foods high in potassium include bananas, oranges, nuts, and potatoes.

• Phosphorus restriction



Decreasing phosphorus intake is recommended to protect bones. Eggs, beans, cola

drinks, and dairy products are examples of foods high in phosphorus.

In chronic kidney disease, several medications can be toxic to the kidneys and may need

to be avoided or given in adjusted doses. Among over-the-counter medications, the following

need to be avoided or used with caution:

• Certain analgesics - Aspirin; nonsteroidal anti-inflammatory drugs

• Fleets or phosphosoda enemas because of their high content of phosphorus

• Laxatives and antacids containing magnesium and aluminum such as Milk of Magnesia

and Mylanta

• Ulcer medication H2-receptor antagonists

• Decongestants especially if you have high blood pressure

• Alka Seltzer because contains a lot of salt

• Herbal medications

MEDICAL TREATMENT

There is no cure for chronic kidney disease. The four goals of therapy are as follows:

1. To slow the progression of disease

2. To treat underlying causes and contributing factors

3. To treat complications of disease

4. To replace lost kidney function

Strategies for slowing progression and treating conditions underlying chronic kidney

disease include the following:

• Control of blood glucose

Maintaining good control of diabetes is critical. People with diabetes who do not

control their blood glucose have a much higher risk of all complications of diabetes,

including chronic kidney disease.

• Control of high blood pressure

This also slows progression of chronic kidney disease. It is recommended to keep

your blood pressure below 130/80 mm Hg if you have kidney disease. It is often useful to

monitor blood pressure at home. Blood pressure medications known as angiotensin

converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) have special benefit in protecting the kidneys.

• Diet

Diet control is essential to slowing progression of chronic kidney disease and

should be done in close consultation with your health care provider and a dietitian.

http://www.emedicinehealth.com/script/main/art.asp?articlekey=2260






The complications of chronic kidney disease may require medical treatment.

• Fluid retention can be treated with any of a number of diuretic medications, which

remove excess water from the body. However, these drugs are not suitable for all

patients.

• Anemia can be treated with erythropoiesis stimulating agents. Erythropoiesis stimulating

agents are a group of drugs that replace the deficiency of erythropoietin, which is

normally produced by healthy kidneys.

• Bone disease develops in patients due to an inability to excrete phosphorus and a failure

to form activated Vitamin D. In such circumstances, doctors may prescribe drugs binding

phosphorus in the gut, and may prescribe active forms of vitamin D.

• Acidosis may develop with kidney disease. The acidosis may cause breakdown of

proteins, inflammation and bone disease.

DIALYSIS

In end-stage renal disease, kidney functions can be replaced only by dialysis or by kidney

transplantation. There are two types of dialysis 1) hemodialysis and 2) peritoneal dialysis.

1. Hemodialysis

Hemodialysis involves circulation of blood through a filter on a dialysis machine.

Blood is cleansed of waste products and excess water. The acid levels and the

concentration of various minerals such as sodium and potassium in the blood are

normalized. The blood is then returned to the body.

• Long-term dialysis requires access to a blood vessel so that the machine has a

way to remove and return blood to the body. This may be in the form of adialysis catheter or an arteriovenous fistula or graft.

• A catheter may be either temporary or permanent. These catheters are either

placed in the neck or the groin into a large blood vessel. These catheters are

prone to infection and may also cause blood vessels to clot or narrow.

• The preferred access for hemodialysis is an arteriovenous fistula wherein an

artery is directly joined to a vein. The vein takes two to four months to enlarge

and mature before it can be used for dialysis. Once matured, two needles are

placed into the vein for dialysis. One needle is used to draw blood and run

through the dialysis machine. The second needle is to return the cleansed

blood.



• An arteriovenous graft is placed in patients who have small veins or in whom

a fistula has failed to develop. The graft is made of artificial material and the

dialysis needles are inserted into the graft directly.

• These venous access devices usually can be placed with local anesthesia on an

outpatient basis.

• Hemodialysis typically takes three to five hours and is needed three times a

week.

• A dialysis center is needed for hemodialysis.

• Home hemodialysis is possible in some situations. A care partner is needed to

assist you with the dialysis treatments. A family member or close friend are

the usual options.

2. Peritoneal dialysis

Peritoneal dialysis utilizes the lining membrane (peritoneum) of the abdomen as a

filter to clean blood and remove excess fluid. A catheter is implanted into the abdomen

by a minor surgical procedure. Peritoneal dialysis may be performed manually or by

using a machine.

• About 2 to 3 liters of dialysis fluid are infused into the abdominal cavity

through this catheter. This fluid contains substances that pull wastes and

excess water out of neighboring tissues.

• The fluid is allowed to dwell for two to several hours before being drained,

taking the unwanted wastes and water with it.

• The fluid typically needs to be exchanged four to five times a day.

• Peritoneal dialysis offers much more freedom compared to hemodialysis since

patients do not need to come to a dialysis center for their treatment. They can

carry out many of your usual activities while undergoing this treatment.

TRANSPLANTATION

Kidney transplantation offers the best outcomes and the best quality of life. Transplanted

kidneys may come from living related donors, living unrelated donors, or people who have died

of other causes (cadaveric donors). In people with type I diabetes, a combined kidney-pancreastransplant is often a better option.

However, not everyone is a candidate for kidney transplant. Patients need to undergo

extensive testing to ensure their suitability for transplantation. Also, there is a shortage of organs

for transplantation, requiring patients to wait months to years before getting a transplant.





A person who needs a kidney transplant undergoes several tests to identify characteristics

of his or her immune system. The recipient can accept only a kidney that comes from a donor

who matches certain of his or her characteristics. The more similar the donor is in these

characteristics, the greater the chance of long-term success of the transplant. Transplants from a

living related donor generally have the best results.

Transplant surgery is a major procedure and generally requires four to seven days in the

hospital. All transplant recipients require lifelong immunosuppressant medications to prevent

their bodies from rejecting the new kidney. Immunosuppressant medications require careful

monitoring of blood levels and increase the risk of infection as well as some types of cancer .

PREVENTION

Chronic kidney disease cannot be prevented in most situations. You may be able to

protect your kidneys from damage, or slow the progression of the disease by controlling your

underlying conditions.

• Kidney disease is usually advanced by the time symptoms appear. If someone is at high

risk of developing chronic kidney disease, it is better to inquire for diagnostic

examinations and screening.

• If a person has a chronic condition such as diabetes, high blood pressure, or high

cholesterol, follow the treatment recommendations of the physician. Monitoring and

aggressive treatment of the diseases is advised.

• Avoid exposure to drugs especially NSAIDs (nonsteroidal anti-inflammatory drugs),

chemicals, and other toxic substances as much as possible.

ANATOMY AND PHYSIOLOGY















The kidneys are the primary organs of the urinary system in vertebrates. The kidneys

filter the blood, remove the wastes, and excrete the wastes in the urine. About 1,300 milliliters of

blood flow through the kidneys each minute (about 400 gallons a day). From this blood the

Malphigian corpuscles extract about 170 liters of filtrate a day. As this fluid passes down the

uriniferous tubules it is almost all reabsorbed. Only about 1.5 liters are left in the tubules to carry

away the waste products.

The whole blood supply passes through the kidneys every 5 minutes, ensuring that waste

materials don't build up. The renal artery carries blood to the kidney, while the renal vein carries

blood, now with much lower concentrations of urea and mineral ions, away from the kidney. The

urine formed passes down the ureter to the bladder.

LOCATION, SHAPE, AND SIZE OF THE KIDNEYS

The kidneys are paired, bean-shaped organs. Adult human kidneys are approximately 12

cm long, 6 cm wide and 3 cm thick. They are situated in the abdominal cavity, just below the rib-cage, one on either side of the spine. More specifically, they lie between the twelfth thoracic and

third lumbar vertebrae.

The right kidney usually is slightly lower than the left because the liver displaces it

downward.



The kidneys, protected by the lower ribs, lie in shallow depressions against the posterior

abdominal wall and behind the parietal peritoneum. This means they are retroperitoneal.

Each kidney is held in place by connective tissue, called renal fascia, and is surrounded

by a thick layer of adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous,

connective tissue known as the renal capsule closely envelopes each kidney and provides support

for the soft tissue that is inside.

STRUCTURE OF THE KIDNEY

Each kidney has an indentation, called the hilum, on the medial side. The hilum leads to a

large cavity, called the renal sinus, within the kidney. The ureter and renal vein leave the kidney,

and the renal artery enters the kidney at the hilum.

The outer, reddish region, next to the capsule, is the renal cortex. This surrounds a darker

reddish-brown region called the renal medulla. The renal medulla consists of a series of renal

pyramids, which appear striated because they contain straight tubular structures and blood

vessels. The wide bases of the pyramids are adjacent to the cortex and the pointed ends, called

renal papillae, are directed toward the center of the kidney. Portions of the renal cortex extend

into the spaces between adjacent pyramids to form renal columns. The cortex and medulla make

up the parenchyma, or functional tissue, of the kidney. The central region of the kidney contains

the renal pelvis, which is located in the renal sinus and is continuous with the ureter. The renal

pelvis is a large cavity that collects the urine as it is produced. The periphery of the renal pelvis

is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae of

each pyramid and collects urine from that pyramid. Several minor calyces converge to form a

major calyx. From the major calyces the urine flows into the renal pelvis and from there into the

ureter.

Each kidney contains over a million functional units, called nephrons, in the parenchyma

(cortex and medulla). The nephrons make up the bulk of the kidney tissue and join up with larger

collecting tubes that eventually form the main urine-carrying duct – the ureter.

FUNCTIONS OF THE KIDNEY

The work of the kidneys is much more than just the removal of waste, however. Other

functions of the kidneys include: Helping control the amount of water lost to the outside world –

most important in land animals.

• Helping regulate the of the blood and the general balance of ions in the blood, and hence

in the body fluid as a whole.



• Conserving essential substances such as glucose and amino acids.

ANATOMY AND PHYSIOLOGY OF THE NEPHRON

The blind end of each nephron, or kidney tubule, lies in the cortex and may be likened to

a champagne glass, the walls and stem of which are hollow and one cell thick. The bowl of the

tubule is known as the Bowman's capsule (or the glomerular capsule). It surrounds an elaborate

knot of blood capillaries – tiny branches of the renal artery – called the glomerulus. Each

Bowman's capsule and glomerulus together form the Malpighian body.

The hollow stem of the champagne glass is the upper part of the tubule. This descendsinto the medulla where it narrows before turning upwards and ascending back into the cortex,

increasing in diameter again. The thin portion of the tube is known as the loop of Henle and is

primarily concerned with the absorption of water. The ascending limb of the tubule joins a

collecting duct which joins with others before eventually discharging its urine into the ureter.

In effect, each Bowman's capsule is a tiny filter. Blood containing waste substances,

proteins, sugars, etc., is forced to the kidneys by the pumping action of the heart. Under pressure,

a solution is driven out of the capillaries of the glomerulus through the walls of the capsule into

its hollow interior. The solution in the capsule is blood plasma minus the large molecules. These

are two big to pass through the capillary wall.

From the capsule the fluid passes along the tubule. Many of the substances in it are

absorbed through the tubule wall into the blood capillaries that envelop this, so that it gradually

becomes more concentrated. Organic molecules such as some amino acids and glucose, some

salts and water are absorbed in the descending or proximal limb of the tubule, while more water

and salts are absorbed in the ascending or distal limb. Certain poisonous or toxic substances that

have been rendered harmless are released into the urine by the tubules, together with potassium

and hydrogen. Measurements of the amounts of various substances present in the blood and in

the urine show striking differences. The concentration of the principal waste substance in the

urine (urea) is normally 70 times as great as it is in the blood, yet, surprisingly enough, some

urea is reabsorbed, since a certain blood concentration is needed. Ninety times more sulfate, 9

times more potassium, and 25 times more uric acid occur in the urine than in the blood. On the

other hand no glucose, fatty substances, proteins, or bicarbonate ions normally occur in the urine,

whereas considerable quantities occur in the blood.The normal daily output of urine is between two and a half to three pints, yet it is

calculated that a total of nearly 300 pints of fluid is filtered by the kidneys during that time. They

not only reabsorb a vast volume each day; they also regulate its content so that the correct levels

of essential substances are maintained in the body fluids.



The juxtaglomerular apparatus, which monitors blood pressure and secretes renin, is

formed from modified cells in the afferent arteriole and the ascending limb of the nephron loop.

III. CASE STUDY PROPER

A. General Data

Name: Marife Del Rosario Esquibel

Age: 30 years old

Birth date: October 3, 1979

Sex: Female

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Name of Mother: Zenaida Telar

Address:Brgy. Madulao Catanauan, Quezon Province

Department: Quezon Medical Center - Internal Medicine

Bed No.: 319

Chief Complaint: Dizziness and body weakness

Initial Diagnosis: Anemia chronic disease, renal disease, body dyscrasia

Final Diagnosis: Chronic kidney disease secondary to chronic glomerulonephritis

Date of Admission: September 6, 2009

Time of Admission: 8:14pm



Attending Physician: Dra. Yvette Panganiban Luce

Date of Discharge: September 14, 2009

Time of Discharge: 2:00pm

Case Number: 09090369

A. Physical Assessment

• General Appearance

> Conscious and coherent

> Pale in appearance

• Skin

> absence of cyanosis

> with dry skin

> cold clamming skin

> no rashes or lesions noted

> with fair skin turgor

• Initial Vital Signs and Other Anthropometric Measurements

> Temperature: 36.3°C

> Pulse Rate: 85bpm

> Respiration Rate: 16bpm

> BP: 130/80mmHg

• Head/Face

> With black and good hair distribution

> No dandruffs and scalp damage noted

> With symmetrical facial features

• Eyes

> eyebrows evenly distributed, symmetrically aligned with equal

movement

> eyelids intact, no discoloration and closes symmetrically

> With yellowish sclera

> With pale conjuctiva





• Extremities

> No lesion noted on both extremities

> No palpable mass noted

> With slightly pale nailbeds on both upper and lower extremities

> With capillary refill time of 1-2 secs.

B. History of Present Illness

One week prior to admission the pt. had experienced episodes of dizziness and

DOB, she was confined to a primary hospital in Catanauan but does not resolved and

eventually was admitted on September 6, 2009 at Quezon Medical Center. She was

diagnosed of Chronic Kidney Disease secondary to AGN. She’s also experiencing the

abdominal pain, vomiting and nausea.

C. History of Past Illness

According to the patient, when she was still a child, she was also unable to tolerate doing

heavy activities. Other health problems that she encountered were cough and colds.

D. Familial Health History

According to the patient, they have history of diabetes mellitus ,heart stroke and

hypertension.

E. Personal and Social History:

The patient is living a simple life in a barrio together with her husband and son. She is

working in a farm. She’s fond of drinking alcohol beverages together with her neighborhood and

she also smokes.

F. Course in the Ward

• Septenber 6, 2009 (day 1)



> Marife Esquibel, 30 years old, female/married, was admitted in Quezon

Medical Center, episodes of dizziness and DOB prior to admission.

> Her admitting doctor, Dra. Luce ordered to monitor her vital signs every

shift, to have CBC stat, urinalysis, creatinine stat, ECG,BUN.

> Her first of IVF was D503 NaCl X KVO. The medications given to her

were clonidine 75mg 1 tab SL now, amlodipine 50mg 1tab OD,

omeprazole 20mg 1 cap BID

> She was also for transfusion of 4 “u” PRBC properly type and cross match

> She was ordered to monitor vital signs every 4 hours and monitor intake

and output every shift.

• September 7, 2009 (day 2)

> The doctor ordered to continue present medications

> For possible hemodialysis and facilitate blood transfusion

> Medications ordered were NaHCO3 1 tab OD, ketosteril 600mg 2tabs TID


> Dr. Luce ordered to facilitate UTZ and ordered IVF of PNSS 1L x KVO

as her 2nd bottle.

> The doctor also ordered for referral to nephro


> Medication ordered were cefexime 250mg 1 cap BID, FeSO4 1 cap OD,

erypoetin 4000 “u” SQ 2 x a day and folic acid 1 tab OD


> The doctor ordered to facilitate BT.

> IVF of PNSS 1L KVO was again ordered as her 3rd bottle.

•

September 11, 2009 (day 6)

> The doctor ordered to facilitate hemodialysis once with funds

> IVF of PNSS 1L x KVO was again ordered as her 4 th bottle



• September 12, 2009

> Medication ordered were captopril 20g 1 tab SL prn for BP 140/90

> Facilitate repeat CT scan.

> IVF of PNSS 1L x KVO was again ordered as her 5 th bottle.


> The doctor ordered referral to hemodialysis.

> HAMA


> HAMA

G. Laboratory Analysis and Examination

September 6, 2009

Hematology

CBC RESULT NORMAL VALUE INTERPRETATION

Hemoglobin 4.5g/dl 12-15gm/dl Anemia

Hematocrit 14 vol % 30-40 vol % Anemia

WBC 5,000/cumm 5,000 – 10,000/cumm Normal

Differential Count

Neuthrophils 77 40-60% infection

Lymphocytes 35 35-40% Normal



• Nursing Responsibilities

Assess blood values

Assess for contributing factors

Advise to perform deep breathing exercise

Maintain high back rest

Encourage to drink enough amount of water

Advise to eat foods rich in iron like meat liver and green leafy vegetables

Encourage to eat foods rich in Vitamin C like guava, oranges and suha

Stress the importance of frequent hand washing

Advise on proper personal hygiene

Encourage to have adequate rest and sleep periods

Stress the importance of strict adherence to treatment regimen

Blood Chemistry

COMPONENTS RESULT NORMAL VALUES INTERPRETATION

Na 136 mmol/L 136-146 mmol/L normal

K 4.1 mEq/L 3.5-5 mEq/L normal

September 8, 2009

Urinalysis

Components Result Normal Value Interpretation

Color Yellow Yellow Normal

Transparency Turbid Clear Abnormal

Reaction 1.0 4.8-7.8

S

pecific Gravity 7.5 1.015-1.025


Assess urinalysis values



Advise to avoid eating salty and junk foods

Advise to limit taking carbonated drinks like soft drinks







Blood Chemistry

CONPONENTS RESULT NORMAL VALUES INTERPRETATION

Creatinine 27.5 0.3-1.3 Kidney is not

functioning well

•Nursing Responsibilities

Assessed for signs and symptoms of increased creatinine such as urinary

frequency.

Instructed pt. to avoid foods that are rich in salts and fats.

September 12, 2009

Hematology


Hemoglobin 7.4g/dl 12-15gm/dl AnemiaHematocrit 22.0 vol % 30-40 vol % Anemia

WBC 8, 600/cumm 5,000 – 10,000/cumm Infection

Differential Count

Neuthrophils 75 40-60% Infection

L

ymphocytes 35 35-40% Normal


Assess blood values













September 13, 2009

Hematology


Hem

oglobin 7.4g/dl 12-15gm/dl Anemia

Hematocrit 22.0 vol % 30-40 vol % Anemia

WBC 9,000/cumm 5,000 – 10,000/cumm Infection

Differential Count

Neuthrophils 72 40-60% Infection

Lymphocytes 36 35-40% Normal


Assess blood values











EVALUATION

On September 14, 2009, the patient went home against medical advised and bought the

take home medications that were instructed by the doctor. She refused dialysis because of money



restrictions but followed the diet instructed by the doctor. She loves to eat salty and canned

goods before but she will not take those kinds of food anymore. She has enough knowledge on

her disease and knows the consequences of what she is doing. There is no cure on her disease

and the only thing that she can do is slow the destruction of her kidney that’s why she follows all

the doctors of the doctor as long as their financial capacity can.

Through the nurse and client interaction, we learned how to take care of a patient with

chronic kidney disease and able to teach and explain to her the proper way of taking care of

herself. The students were able to trace and know how this disease starts and able to interpret

laboratory finding and studies and relate it to the cause of the disease and how it develops.

Documents

CKD - Case Pres