Group 6 (Case Study)

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Capitol UniversityCORRALES, EXT./ OSMEÑA STS. CAGAYAN DE ORO CITY

A CASE STUDY

On

CHRONIC KIDNEY DISEASE SECONDARY TO

DIABETIC NEPHROPATHY; ANEMIA

MR. RYAN MANUEL V. NASOL, RN

Clinical Instructor

August 14, 2010



I. Introduction

Diabetes mellitus is a condition in

which the pancreas no longer producesenough insulin or cells stop responding tothe insulin that is produced, so thatglucose in the blood cannot be absorbedinto the cells of the body. Symptoms

include frequent urination, lethargy,excessive thirst, and hunger. Thetreatment includes changes in diet, oralmedications, and in some cases, dailyinjections of insulin.

The most common form of diabetes isType II, It is sometimes called age-onsetor adult-onset diabetes, and this form of diabetes occurs most often in people whoare overweight and who do not exercise.



I. Introduction

Anemia is a condition that occurswhen the number of red blood cells

(RBCs) and/or the amount of hemoglobinfound in the red blood cells drops belownormal. Red blood cells and thehemoglobin contained within them arenecessary for the transport and delivery of oxygen from the lungs to the rest of thebody. Without a sufficient supply of oxygen, manytissues and organsthroughout the body can be adverselyaffected. Anemia can be mild, moderate or severe depending on the extent to whichthe RBC count and/or hemoglobinlevels are decreased.



I. Introduction

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 andexperiencing 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 thosewith 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.



II. CLIENT·S PROFILE

1.Health Perception and Health

Management Pattern

Chief complaint:

P

atient was admitted due to shortness of breath and edema formation. Last

admission was June this year also due to

shortness of breath, at Zamboanga del

Sur

History of present illness;

The patient was diagnosed with Diabetes

Mellitus 16 years ago




Last October 2009, the patient manifestedsigns and symptoms of glaucoma. While he

was at home, he got so angry which elevated

his blood pressure. He then manifested signs

like redness around his right eye. He also

reported blurring and pain in his right eye.They went to see a doctor and were referred

to a specialist of ophthalmology at Cebu City.

After the consultation, he agreed with the

advice of undergoing laser treatment to treat

his glaucoma. After six sessions, they wenthome to Aurora. After going home, he was still

complaining about blurredness of vision in his

right eye. Few weeks later, the other eye

became affected and he reported blurredness

in both eyes.




When they went back to the specialist they

were advised to undergo a surgery which costs ahuge amount of money. When they asked for anyassurance for the blurredness to be relieved after undergoing the surgery, they were given theassurance which made them decide not to take therisk. Few weeks later the right eye became totallyblind and the left eye had an angular blurredness.When they went back to the specialist for the thirdtime, it was found out that the left eye had a bloodclot covering the pupil.

Patient was diagnosed with CKD lastDecember 2009.

2weeks prior to admission, there was onset of

shortness of breath, with dizziness and edema.By the physicians order, the patient started

taking Sodium Bicarbonate and CalciumCarbonate, but did not comply with the other drugwhich is Ketosteril.




General Appearance: Patient appears weak, and bloated.

Social History:

Before diagnosed, patient is a chain

smoker, smokes almost three packs of

cigarette a day and a heavy drinker. He

socializes with his friends and goes home

late and very drunk at least twice a week.

History of allergies:

Patient doesn¶t have any known allergies




2. Nutrition and Metabolic PatternEating pattern:

The patient has fair-good appetite for

eating. There are times that he could

consume a whole share of his diet butthere are also times in which he doesn¶t

have any appetite at all which sometimes

coincide with his tantrums. No known

eating discomforts.

Special diet:

Patient was ordered low salt, low fat ,

diabetic diet. No intravenous fluid was

used




Physical examination of the mouth:

MOUTH: Lips are pale, and dry so as his mucosa.

His tongue is midline and dental caries noted, with

missing teeth, and pale gums.

PH ARYNX: Uvula is midline and tonsils not

inflamed

NECK: Trachea is midline and thyroids are not

palpable and normal.

SKIN: General color is pale with rough texture, poor

turgor and warm temperature. Ecchymosis was

noted on both arms

Other pertinent data:

Presence of wound dressing on right neck due to

Intra-jugular catheter insertion for his dialysis.



II. CLIENT·S

PROFILE

3. Elimination Pattern

Bowel Pattern:

Patient normally defecates once/ twice in a day

with a semi-formed, yellowish stool. No

discomforts on bowel elimination. No problems

with hemorrhoids and incontinence. Withnormoactive bowel sounds.

Urination pattern:

Patient urinates almost 4-6 times a day, with

yellow or amber colored and scanty urine.

Physical assessment:

The patient had normoactive bowel sounds and

tympanic when auscultated. His abdomen is

globular and symmetrical.



II. CLIENT·S

PROFILE

4. Activity ± Exercise Pattern

Before hospitalization, patient¶s type of exercise is

only walking around home premise almost

everyday. The patient likes to talk and have night-

outs with friends as leisure.Cardiovascular status:

Orthopnea reported, with capillary refill of 3

seconds. Palpitations are reported upon exertion.

Precordial area is flat. The point of maximal

impulse is at the apical area and the A

pical ratereaches up to 89 and arrhythmia is noted. Heart

sounds are faint and irregular. The peripheral

pulses are asymmetrical and faint.



II. CLIENT·S

PROFILE

Respiratory status Breathing pattern is irregular. Wheezes

heard at left lung, ronchi and crackles atthe right.

The Anteroposterior Lateral ratio is 1:2 and

the lung expansion is symmetrical. Tactilefremitus is also symmetrical. The lungs areresonant when the back is percussed. Thepatient has a productive cough with whitesputum.

Patient has Oxygen inhalation via nasalcannula, regulated at 4 LPM.

Activities of daily Living

Range of motion symmetrical, withstaggering gait.



II. CLIENT·S

PROFILE

5. Cognitive ± Perceptual Pattern

Level of consciousness:

Patient is conscious and oriented totime, place, and person.

Patient¶s emotional state is anxious.Head: Head is normocephalic, with

symmetrical facial movements. Hair is fine,and scalp is clean.

Eyes: Eyelids are symmetrical. Periorbitalregion is on edema, while conjunctiva ispale. Sclera is icteric. Pupils have sluggishreaction to light, having a size of 4mm onthe right eye and 3mm on the left.Peripheral vision is decreased/limited.



II. CLIENT·S

PROFILE

Ears: External Pinnae is normoset. No ear

discharges, tympanic membrane intact. Gross

hearing is intact

Nose: Nasal septum is midline, mucosa is

pale, both nasal openings are patent, with no

discharges and non tender sinuses

Cognition: Primary language is vernacular.

Patient is a college graduate. No speech deficit

reported, but has some memory changes due to

aging process.

Pain: There is intermittent pain in lower extremities but disappears later on even with

nonpharmacologic treatment is used



II. CLIENT·S

PROFILE

6. Sleep ± Rest Pattern

Usual sleep/rest pattern:

Patient usually sleeps less than 8hours

during night time, but takes time to sleep

during daytime. Sleeping pattern is

usually disturbed due to his irritability, and

coughing, and environmental factors.

Patient has no known history on sleepdisturbances.



II. CLIENT·S

PROFILE

7. Self-perception and Self-concept Pattern The patient is anxious about his condition, and

oftentimes verbalizes that he doesn¶t understandhis feeling.

8. Role ± Relationship Pattern

Marital status: Patient is married, with one child.

Age and health of significant other: Spouse is 50years old and in good condition.

Patient¶s family has a history of diabetes on thematernal side.

Living together with family, but does not have any

occupation. Patient¶s family is worried for patient¶scondition, and is worried regarding financialsupport.

Financial support system would be the wife¶sincome.



II. CLIENT·S

PROFILE

9. Sexuality ± Reproductive Pattern

Patient¶s sexual relation has been greatly

affected by his condition

Patient has no known prostate problems

at present. Does not exercise monthlytesticular examination.

Penis: No discharges noted, and no

lesions

Scrotum: patient manifested hydrocelein the scrotum



II. CLIENT·S

PROFILE

10. Coping ± Stress Tolerance Pattern

One of the recent stressful situations thatcomplicates his feelings is financial crisis of thefamily. His wife took her advance pay from work tosupport hospitalization, and some relatives

donated some of their money for financial help Patient usually manages stress by talking to

friends, also for relaxation

11. Value ± Belief Pattern

Religion: Patient X is a Roman Catholic. Hisfamily continues to pray and ask for guidance fromGod to help them pass through this difficult timethat they are having. They used to go to churchevery Sunday, but was not able to comply with itsince patient¶s hospitalization.



III. ANATOMY

and PHYSIOLOGY



III. ANATOMY

and PHYSIOLOGY



III. ANATOMY

and PHYSIOLOGY



III. ANATOMY

and PHYSIOLOGY



III. ANATOMY

and PHYSIOLOGY



III. ANATOMY

and PHYSIOLOGY



III. ANATOMY

and PHYSIOLOGY



III. ANATOMY

and PHYSIOLOGY



IV. PATHOPHYSIOLOGY



LEGEND:-DIAGNOSIS

- IMPLICATIONS

TYPE II DIABETES MELLITUS

CHRONIC ELEVATIONS OF GLUCOSE IN THE BLOOD.

INCREASED PRESSURE AND SOLUTES (GLUCOSE)

IN THE CIRCULATORY SYSTEM.

INCREASED PRESSURE AND SOLUTES IN THE VESSELS OF THE KIDNEYS.

CHRONIC KIDNEY DISEASE

THICKENING OF THE GLOMERULUS ANDIMPAIRMENT OF THE SELECTIVE PERMEABILITY

OF THE KIDNEYSALLOWING THE LARGER MOLECULE TO PASS.

RED BLOOD CELLS AND ALBUMIN ARE NOT FILTERED AND THUS ARE INCLUDED IN THE

URINE FORMATION

DECREASED SERUM ALBUMIN-2.89MG% (NORMAL VALUE= 3.8-5.1)

DECREASED PRODUCTION OF ERYTHROPOIETINBY THE KIDNEYS

DECREASED STIMULATION OF THE BONE MARROW TO PRODUCE RED BLOOD CELLS

DECREASE LEVELS OF RED BLOODCELLS

3.11 (NORMAL= 4.2-5.4)DECREASED HEMOGLOBIN LEVEL

10.7 (NORMAL= 12.0-16.0)DECREASED HEMATOCRIT LEVEL

34.8 (NORMAL= 37.0 47.0)

ANEMIA





V. LABORATORY RESULTS

COMPLETE BLOOD COUNT

JULY 24, 2010

TEST RESULT UNIT NORM AL V ALUES INTERPRET ATIONS

WBC 11.5 103/uL 5.0-10 HIGH

RBC 3.2 106/uL 4.2-5.4 LOW

HGB 9.1 g/dl 12.0-16 LOW

HCT 28.2 % 37-47 LOW

DIFF. COUNT

LYMPHOCYTE 6.6 % 17.4-48.2 LOW

NEUTROPHIL 82.4 % 43.4-76.2 HIGH

MONOCYTE 9 % 1.0-3.0 HIGH

EUSINOPHIL 1.9 % 0.0-2.0 HIGH

B ASOPHIL 0.1 % 1.0-2.0 NORM AL

PL ATELET 200 103/uL 150-450 NORM AL




JULY 26, 2010

TEST RESULT UNIT NORM AL V ALUES INTERPRET ATIONS

WBC 11.9 103/uL 5.0-10 HIGH

RBC 3.11 106/uL 4.2-5.4 LOW

HGB 8.7 g/dl 12.0-16 LOW

HCT 27.6 % 37-47 LOW

DIFF. COUNT

LYMPHOCYTE 2.9 % 17.4-48.2 LOW

NEUTROPHIL 90.6 % 43.4-76.2 HIGH

MONOCYTE 6.2 % 1.0-3.0 HIGH

EUSINOPHIL 0.3 % 0.0-2.0 HIGH

B ASOPHIL 0 % 1.0-2.0 LOW

PL ATELET 200 103/uL 150-450 NORM AL




JULY 29, 2010

TEST RESULT UNIT NORM AL V ALUES

WBC 9.6 103/uL 5.0-10

RBC 3.91 106/uL 4.2-5.4

HGB 10.7 g/dl 12.0-16HCT 34.8 % 37-47

DIFF. COUNT

LYMPHOCYTE 6.2 % 17.4-48.2

NEUTROPHIL 84.1 % 43.4-76.2

MONOCYTE 0.8 % 1.0-3.0EUSINOPHIL 0 % 0.0-2.0

B ASOPHIL 0 % 1.0-2.0

PL ATELET 200 103/uL 150-450



















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Group 6 (Case Study)