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 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.

Chronic kidney disease is identified by a blood test for creatinine. Higher levels of
creatinine indicate a falling glomerular filtration rate (rate at which the kidneys filter blood) 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 (testing of a urine
sample) 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 (removing a small sample of kidney tissue) are employed to find out if
there is a reversible cause for the kidney malfunction.[1] Recent professional guidelines classify the
severity of chronic kidney disease in five stages, with stage 1 being the mildest and usually causing
few symptoms and stage 5 being a severe illness with poor life expectancy if untreated. Stage 5
CKD is also called established chronic kidney disease and is synonymous with the now outdated
terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).

There is no specific treatment unequivocally shown to slow the worsening of chronic kidney
disease. If there is an underlying cause to CKD, such as vasculitis, this may be treated directly with
treatments aimed to slow the damage. In more advanced stages, treatments may be required for
anemia and bone disease. Severe CKD requires one of the forms of renal replacement therapy; this
may be a form of dialysis, but ideally constitutes a kidney transplant.
II. Patient’s Profile

Ward: B-2
Date of Admission: May 15, 2010
Pt. Name: S.G.
Address:
Age: 42 y/o
Gender: Male
Birth date: May 15, 1968
Religion: Roman Catholic
Educational Status: Undergraduate (2nd year High school)
Nationality: Filipino
Civil Status: Married
Occupation: Army(TSG)
Health Care Financing:
Informant: Patient
Reliability: 100%

Admission Data
Chief complaint: chest pain
Initial diagnosis: Pneumonia community acquired moderate risk pleural
effusion
Final Diagnosis: Pneumonia community acquired moderate risk pleural
effusion
Attending Physician: Dr. Conciller

PAST HEALTH HISTORY

Patient had no history of hospitalization

PERSONAL AND SOCIAL HISTORY

The patient is a TSGT army, a non-smoker, occasional drinker with no allergy to food and drugs.

PRESENT HEALTH HISTORY

2 weeks prior to admission patient had productive cough initially whitish then yellowish phlegm.
No difficulty of breathing, fever was noted. No consultation for was noted for medication. 8 days
prior to admission, still with productive cough now associated with low grade fever. 3 days prior to
admission, patient experienced chest pain, he consult at CGEASH, he was given cefalexin 100mg 1
tab, ambroxol three times a day and mefenamic which gives relief.

1 day prior to admission he consulted back at CGEASH where chest x-ray was done which revealed
pneumonia and pleural effusion.
PHYSICAL ASSESSMENT

AREA TO BE TECHNIQUE FINDINGS REMARKS

ASSESS
Head
Skull Palpation Rounded normocephalic and Normal
Inspection symmetrically smooth skull contour,
uniform consistency, absence of
nodules or masses. W/ frontal,
parietal and occipital prominences,
Scalp Inspection Color is uniform; lighter than the *with dandruff
Palpation normal color of the skin with dandruff
no tenderness
Hair Inspection Evenly distributed; silky and resilent *coarse and
with coarse and dull looking dull hair
Face Inspection Symmetric; palpebral fissures equal in *presence of
Palpation size; symmetric nasolabial folds, edema
symmetric facial movements and
coarse
Eyelids Inspection Skin intact; no discharge no Normal
discoloration, Lids close
symmetrically with scant amount of
secretions
Bilateral blinking, when lids open no Normal
visible sclera above corneas, and
upper and lower borders of cornea are
slightly covered
Eyebrows Inspection Hair evenly distributed skin intact; Normal
symmetrically aligned; equal
movement
Eyelashes Inspection Equally distributed; curled turned Normal
outward
Palpebral Inspection Equal in size Normal
fissures
Conjunctiva Inspection Bulbar conjunctiva is transparent; *pale
some visible capillaries, palpebral conjunctiva
conjunctiva is shiny, smooth, and pink
or red and pale
Sclera Inspection Appears white and clear Normal
Iris Inspection Transparent, no shadows of light Normal
Pupil Inspection Black, equal size, round and smooth, Normal
Illuminated pupil constrictly, Non-
illuminated pupil dilates, constrictly
 looking at near object, dilate looking
at far object
Eye Inspection Right eye is blind, not coordinated; Not
Movement coordinated
movement

Visual Inspection 20/0 distance vision but able to read Right eye is
Activity newsprint blind
Ears Inspection Color same as facial skin, Normal
symmetrical auricle – aligned with
outer canthus of eye, about 10 from
vertical. Mobile, firm and not tender,
pinna recoils after it is folded
Ear canal Inspection Dry cerumen, no lesions, no pus, no Normal
blood, Pinkish clean with scant
amount of cerumen and a few cilia
Hearing Inspection Able to hear watch ticking at left and Normal
Acuity Weber/ Rhine right ear
test -Webers; sound hear in both ears
- Rhines test; sound hear in both ears,
able to hear a whisper spoken 2 feet
away
Nose Inspection Symmetrically and straight no Normal
Palpation discharge/Flaring, has a uniform
color, no swelling/ redness and
discharge on nasal cavities. Nasal
septum is intact and in midline air
moves freely as the client breathes
through the nares
Lips Inspection Symmetry in color; smooth white, Normal
pink gums, no retraction of gums and
a dry chapped lips
Teeth Inspection 32 adult teeth smooth, slightly *2 teeth
yellowish teeth enamel extracted
Tongue Inspection Smooth tongue base with prominent Normal
veins, central position, pink color,
raised papillae
Uvula Inspection Positioned in midline of soft palate Normal
Soft Palate Inspection Light pink, shiny and smooth Normal
Hard palate Inspection Light pink, hard palate, more irregular Normal
texture
Tonsils Inspection Pink and smooth, no discharge and of Normal
normal size
Voice Voice is well modulated Normal
Neck Inspection Muscles equal in size; head centered; Normal
coordinated; smooth movements with
no discomforts
- Thyroid gland not visible on
inspection
 Palpitation Lymph nodes not palpable Normal
-Trachea centered placement in
midline of neck; spaces are equal on
both sides
-Thyroid gland lobes are small,
smooth, centrally located, painless,
and rise freely with swallowing
Thorax Inspection Asterioposterior 1-2 diameter chest Normal
symmetric; vertically aligned

Uniform texture;
Palpation Chest wall intact; no tenderness/ Normal
masses full and symmetric chest
expansion bilateral symmetry and
frimetus heard

3-5 cm;
Diaphragm (higher at right side)

Percussion Vesicular and bronchovesicular sound

Auscultation
Abdomen Inspection Unblemished skin; uniform color, flat Normal
rounded, no evidence of enlargement
of liver/ spleen, symmetric contour;
symmetric

Movement cause by respiration, no

visible vascular pattern

Audible bowel sound

-Absence of arterial bruits
-Absence of friction rub

Auscultation Tympany over the stomach and gas-

filled bowels; dullness especially over
the liver and spleen

No tenderness. relaxed abdomen with

Percussion smooth consistent tension
Upper Normal
Extremities
Arms Inspection Positive for muscle weakness *presence of
Palpation With deformities on left arm fistula on left
No swelling of joints arm
Palms Inspection No skin lesion Normal
Palpitation No callous
Fingers Inspection Joints: Normal
(-) Contractures
Nails: Convex curvature pinkish nail
bed
Blanch test; return to its previous state
after 3-4 seconds.
Lower
Extremities
Legs Inspection Symmetrical in length, no Normal
lumps/masses present on both calves
-Has a bruises discoloration on both
lower portion of the legs

No tenderness

Palpation
Knees Inspection Normal
Sole Inspection White translucent tips; slightly pale in Normal
color
Toes Inspection No tender in palpation *edema is
-Edema is present present
ANATOMY AND PHYSIOLOGY
URINARY SYSTEM
 KIDNEY - are located in the posterior wall of the abdominal cavity;
FUNCTIONS OF THE KIDNEYS
1.Excrete nitrogenous waste from the body
a) Urea
b) Ammonia
c) Creatinine
2.Regulate blood volume
3.Help regulate electrolyte content of the blood
4.Regulate acid-base balance (pH)
5.Regulate blood pressure
6.Regulates red blood cell production

Three Regions in the kidney if sliced in half – renal cortex, renal medulla, renal
pelvis

a)Renal Cortex - Light, outside region, cortex means “bark”

b)Renal Medulla - Dark, triangular structure, form small cone shaped regions
called renal pyramids , each pyramid is separated by renal columns , the lower
ends of the pyramids point to the renal pelvis
c)Renal Pelvis - A basin that collects the urine made by the kidney and helps
form the upper end of the ureter. The edges of the renal pelvis closest to the
renal pyramids are called calyces. Calyces collect the urine formed in the
kidney.

URETERS - long, fibromuscular tubes that connects each kidney to the

bladder
are muscular tubes that propel urine from the kidneys to the urinary bladder

BLADDER - muscular, hollow sac located just behind the pubic bone
It is the organ that collects urine excreted by the kidneys prior to disposal by
urination.

URETHRA - arises from the base of the bladder

connects the urinary bladder to the outside of the body

FORMATION OF URINE
The Nephron Unit
Each kidney contains about 1 million nephron units
The number does not increase after birth
They cannot be replaced if damaged
2 parts
Tubular component (renal tubule)
Vascular component

RENAL TUBULES
Glomerular capsule (Bowman’s capsule) – “C” shaped capsule surrounding the glomerulus
Glomerulus – cluster of capillaries
Proximal convoluted tubule
Loop of Henle – ascending and descending limb
Distal Convoluted tubule
Collecting duct
RENAL VASCULATURE
Receives blood from the renal artery
Renal artery branches into the afferent arterioles
Afferent arterioles feed into Bowman’s capsule
The efferent arterioles exit Bowman’s capsule
The efferent arterioles form the peritubular capillaries
The peritubular capillaries empty into the venules, large veins, and then into the renal veins

URINE FORMATION
Formed in the nephron unit
Water and dissolved substances move through the renal tubules and vessels
Three processes are involved in urine formation
Glomerular filtration
Tubular reabsorption
Tubular secretion
 LABORATORY RESULTS:

Laboratory/ Actual Normal Analysis/Infer Reference

Diagnostic Result Value ence
Test

Arterial Blood
Gas/ May 16,
2010.
Medical-Surgical
Temperature 37.0 Nursing(Brunner &
Suddarth)

7.37 7.34-7.44 Normal Diagnostic and

pH Laboratory Test
38 mmHg 35-45 mmHg Normal Reference(MOSBY)
PCO2 Diagnostic and
Laboratory Test
97 mmHg 75-100 mmHg Normal Reference(MOSBY)
PO2
Diagnostic and
Laboratory Test
11.7 (M: 13 – 18 Abnormal Reference(MOSBY)
Hemoglobin gms/dl gm/dL;) decreased
indicates
anemia. Diagnostic and
22-26 mEq/L Laboratory Test
Reference(MOSBY)
HCO3 17.3
mmol/dl Metabolic
acidosis
Greater Diagnostic and
than or Laboratory Test
O2SAT equal 95% Reference(MOSBY)
97% Normal

Diagnostic and
Laboratory Test
Reference(MOSBY)

Complete
blood count/
May 17, 2010

WBC count 5,000 –

10,000/cu 10,000
Normal
mm
Hemoglobin
8.7 gms/dl (M:13.5 –
18;) Abnormal
Decreased Diagnostic and
indicates Laboratory Test
Anemia Reference(MOSBY)
26%
Hematocrit (M: 40.0 –
48.0) Diagnostic and
Abnormal Laboratory Test
Decreased Reference(MOSBY)
indicates
Anemia
Lymphocytes
6% Diagnostic and
Laboratory Test
25 – 35 Reference(MOSBY)
Fluid: Serum Abnormal
May 18, 2010 Decreased
indicates Sepsis

Urea Nitrogen
Diagnostic and
31 mg/dl Laboratory Test
Reference(MOSBY)
7 – 20

Abnormal
Creatinine increased
indicates renal
failure and
9.25
glomerulonephri
mg/dl .52 – 1.25 tis Diagnostic and
Laboratory Test
Sodium Reference(MOSBY)

Abnormal
increased
134 137 – 150 indicates
glomerulonephri
mmol/L
tis Diagnostic and
Potassium Laboratory Test
Reference(MOSBY)

3.6 – 5.0 Abnormal

decreased
3.8
indicates
Total Bili mmol/L peripheral Diagnostic and
edema Laboratory Test
Reference(MOSBY)
.20 – 1.30

Normal
.22 mg/dl
Diagnostic and
Laboratory Test
Reference(MOSBY)

Normal

Diagnostic and
Laboratory Test
Reference(MOSBY)
 DRUG STUDY

Classification: Mineral and Electrolyte Replacements

CONTRAINDICAT SIDE NURSING

DRUG NAME INDICATION ACTION
ION EFFECTS CONSIDERATION
GENERIC Control of Maintain • Hypercalce • Observe patient
NAME: hyperphosphate cell mia for symptoms of
Constipation,
Calcium mia in ESRD membrane • Renal hypocalcemia
flatulence;
Carbonate and capillary Calculi • Monitor vital
hypercalcaemi
permeability. • Ventricular signs frequently
BRAND NAME Essential for a; metabolic throughout the parenteral
fibrilation
bone alkalosis; therapy
Calsan formation milk-alkali • Monitor for signs
and blood syndrome, and symptoms of
DOSAGE coagulation. tissue- hypercalcemia
Adult: calcification.
Initially 1/2-1-2 Gastric
tab/day hypersecretion
Maintenance: and acid
1/2-1 tab/day
rebound

Classification: Anti-ulcer agents

CONTRAINDICAT SIDE NURSING

DRUG NAME INDICATION ACTION
ION EFFECTS CONSIDERATION
 GENERIC Management of Acts as an • Hypocalcem Edema, • Assess fluid
NAME: metabolic alkalinizing ia flatulence, balance throughout
Sodium acidosis agent by • Excessive gastric therapy
Bicarbonate releasing Chloride loss distention, • Assess patient for
bicarbonate metabolic
• Severe signs of acidosis
BRAND NAME ions.
abdominal case
alkalosis, • Assess for
Following hypernatremia epigastric or abdominal
with unknown
Citrocarbonate oral pain.
cause.
administratio
DOSAGE n, releases
bicarbonate,
Adult:
which is
Initially 325mg-
capable of
2g 1-4 times
neutralizing
daily or ½ tsp
gastric acid
every 2hr as
needed.

Classification: Anti-infectives

CONTRAINDICAT SIDE NURSING

DRUG NAME INDICATION ACTION
ION EFFECTS CONSIDERATION
GENERIC Treatment of Binds to • Serious Diarrhea, • Assess for signs of
NAME: respiratory, bacterial cell hypersensitivity to nausea, infections
Cephalosporins skin, bone and wall penicillin vomiting, • Before initiating
joint infections. membrane, cramps, rashes, therapy, obtain a history
BRAND NAME causing cell anaphylaxis of reaction to penicillin
death. and cephalosporins
Cefuroxime

DOSAGE
Adult:
200-400mg
every 12 hr

Classification: Anti-anemic drugs

CONTRAINDICAT ADVERSE NURSING
DRUG NAME INDICATION ACTION
ION REACTION CONSIDERATION
 Provides Contraindicated in Tell patient to continue
GENERIC Iron deficiency. elemental iron, hemosiderosis and GI: N/V, regular dosing schedule
NAME: an essential hemochromatosis. constipation, if she misses a dose.
ferrous sulfate component in Also contraindicated black stools Patient shouldn’t
the formation of in patients with double the dose.
hemoglobin hemolytic anemia Other: elixir To avoid staining teeth,
unless IDA is present. may stain give elixir iron
BRAND
teeth preparations with straw.
NAME:
Use cautiously in Check for constipation;
Iberet
peptic ulcer, record color and
ulcerative colitis and amount of stool. Teach
DOSAGE: 1
regional enteritis dietary measures for
tab BID preventing constipation.
Do not crushes, chew,
sustain or release
preparations.

NURSING CARE PLANS

ASSESSMENT NURSING GOAL PLAN INTERVENTION RATIONALE EVALUATION
DIAGNOSI
OBJECTIVE Fluid volume After 8 hours of  Note  To Goal met. The
Decreased excess related nursing amount/r gain patient was able
Hgb= to chronic renal intervention, the ate of all basel to
11.7gms/dl failure patient will: fluid ine
Edema (face, >Demonstrate intakes data Demonstrate
lower back, behaviours to from all behaviours to
feet) monitor fluid sources.  To monitor fluid
status and  Note identi status.
reduce signs of fy
recurrence of edema signs
fluid excess of
 Restrict fluid
fluid and exces
sodium s
intake as
indicated.

 To
 Administ prom
er ote
medicati elimi
ons ex. natio
Diuretics. n of
Review dietary exces
restrictions and s
substitutes for fluid.
salts.

 To
prom
ote
welln
ess
ASSESSMENT NURSING GOAL PLAN INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OBJECTIVE Risk for After 8 hours of  Note signs  To Goal met. The
Decreased Hgb= infection related nursing and assess patient was able
11.7gms/dl to decreased intervention, the symptoms contri to
hemoglobin patient will: of sepsis. buting
>Identify  Stress factors  Identify
interventions to proper use . intervent
prevent/ reduce of proper ions to
risk of infection. protective  To reduce
equipment reduce risk of
existin infection
 Instruct g risk s.
client to factors
protect the
integrant
of skin,
care for  To
lesion, and promo
prevention te
of spread wellne
of ss.
infection.
ASSESSMENT NURSING GOAL PLAN INTERVENTION RATIONALE EVALUATIO
DIAGNOSIS N
 OBJECTIVE Altered After 8 hours of  Assess drug  To Goal partially
Decreased Weight Nutrition: Less nursing interaction, assess met. The
= 75kg-53kg than body intervention, the disease contrib patient was
requirements patient will: effects. uting able to
Poor muscle tone related to >Demonstrate  Assess factors.
inability to progressive weight,  Achie
absorb weight gain measure  To ve a
nutrients toward goal body fat and evaluat weig
muscle e ht
mass degree gain
of from
 Provide diet deficit 53kg-
modificatio 60kg.
ns.

 To
 Use establis
flavouring h
agents if nutritio
salt is nal
restricted. plan
that
meets
individ
ual
needs.

 To
enhanc
e food
satisfac
tion
and
stimula
te
appetit
e

ASSESSMENT NURSING GOAL PLAN INTERVENTION RATIONALE EVALUATIO

DIAGNOSIS N
OBJECTIVE Impaired After 4 hours of  Provide  To Goal met. The
 Impaired mobility related nursing activities reduce patient was
ability to to decreased intervention the with the able to
turn side muscle strength patient will be adequate rest fatigue
to side. as manifested able move safety period.  move
 Irritable by limited and  Advise to  To safely
 Limited ROM. independently. move hands exercise and
ROM and legs of body indep
slowly parts enden
 Encourage and tly.
participation develop
in self care muscle
strength

 Enhanc
es self
concept
and
sense of
indepen
dence
ASSESSMENT NURSING GOAL PLAN INTERVENTION RATIONALE EVALUATIO
DIAGNOSIS N
OBJECTIVE Ineffective After 4 hours of  Identify  To Goal met. The
 Failure to therapeutic nursing assess patient was
knowledge able to
include regimen intervention the contrib
management patient will: and
treatment uting
regimens related to expectatio factors  Learn
in daily knowledge Participate in n of client the
routine. deficit. problem solving to factor
of factors
 To s
treatment. assist interfe
interfering with
 Reinforce client to ring
integration of
develop
treatment previous treatm
strategi ent
regimen. instruction es to regim
s, and improve en.
rationale, manage
using a ment of
therape
variety of
utic
learning manage
modalities ment
 Emphasize
knowledge  To
promote
and
wellnes
understand s.
ing of the
need for
treatment