Capitol University

College of Nursing

A CASE STUDY
On
A patient with
CHRONIC KIDNEY DISEASE SECONDARY TO
DIABETIC NEPHROPATHY; ANEMIA

A written Requirement Presented to

MR. JONATHAN L. GESTA, R.N
Clinical Instructor

In Partial Fulfillment of the Final Requirement In

RELATED LEARNING EXPERIENCE 40
Group 7

By
Jade Ruth L. Piamonte

March 20, 2011

 TABLE OF CONTENTS

• I. Introduction

• II. Client’s Profile

• III. Anatomy and Physiology

• IV. Pathophysiology

• V. Diagnostic Procedures and Lab Results

• VI. Drug Study

• VII. Nursing Care Plan

• VIII. Discharge Plan

• IX. Learning Insights

• X. Reference
I. INTRODUCTION
Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or
cells stop responding to the insulin that is produced, so that glucose in the blood cannot be
absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst,
and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily
injections of insulin.

The most common form of diabetes is Type II, It is sometimes called age-onset or adult-
onset diabetes, and this form of diabetes occurs most often in people who are overweight and who
do not exercise. Type II is considered a milder form of diabetes because of its slow onset
(sometimes developing over the course of several years) and because it usually can be controlled
with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes,
however, are the just as serious as those for Type I. This form is also called noninsulin-dependent
diabetes, a term that is somewhat misleading. Many people with Type II diabetes can control the
condition with diet and oral medications, however, insulin injections are sometimes necessary if
treatment with diet and oral medication is not working.
The causes of diabetes mellitus are unclear; however, there seem to be both hereditary (genetic
factors passed on in families) and environmental factors involved. Research has shown that some
people who develop diabetes have common genetic markers. In Type I diabetes, the immune
system, the body’s defense system against infection, is believed to be triggered by a virus or
another microorganism that destroys cells in the pancreas that produce insulin. In Type II diabetes,
age, obesity, and family history of diabetes play a role. (http://nursingcrib.com/case-study/diabetes-
mellitus-case-study/)

In Type II diabetes, the pancreas may produce enough insulin, however, cells have become
resistant to the insulin produced and it may not work as effectively. Symptoms of Type II
diabetes can begin so gradually that a person may not know that he or she has it. Early signs are
lethargy, extreme thirst, and frequent urination. Other symptoms may include sudden weight loss,
slow wound healing, urinary tract infections, gum disease, or blurred vision. It is not unusual for
Type II diabetes to be detected while a patient is seeing a doctor about another health concern that
is actually being caused by the yet undiagnosed diabetes.

Diabetes mellitus is a common chronic disease requiring lifelong behavioral and lifestyle
changes. It is best managed with a team approach to empower the client to successfully manage
the disease. As part of the team the, the nurse plans, organizes, and coordinates care among the
various health disciplines involved; provides care and education and promotes the client’s health
and well being. Diabetes is a major public health worldwide. Its complications cause many
devastating health problems. (http://www.nlm.nih.gov/medlineplus/ency/article/003263.htm)
 Anemia is a condition that occurs when the number of red blood cells (RBCs) and/or the
amount of hemoglobin found in the red blood cells drops below normal. Red blood cells and the
hemoglobin contained within them are necessary for the transport and delivery of oxygen from the
lungs to the rest of the body. Without a sufficient supply of oxygen, many tissues and organs
throughout the body can be adversely affected. Anemia can be mild, moderate or severe depending
on the extent to which the RBC count and/or hemoglobin levels are decreased. It is a fairly common
condition, affecting both men and women of all ages, races, and ethnic groups. However, certain
people are at an increased risk of developing anemia. These include people with diets poor in iron
and vitamins, chronic diseases such as kidney disease, diabetes, cancer, inflammatory, a family
history of inherited anemia, chronic infections such astuberculosis or HIV, and those who have had
significant blood loss from injury or surgery. (http://www.scribd.com/doc/19465471/Case-Study-on-
Chronic-Kidney-Disease)

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. 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 (http://www.nhlbi.nih.gov/health/dci/Diseases/)
 One of the formidable parts of doing a case study is choosing what case to present. So, I
presented Chronic kidney Disease Secondary to Diabetic Nephropathy because with this patient I
had, I was really able to gain lots of knowledge, I was able to render not just care but passion
towards my craft. I’ve known some people with the same condition of my client, yet there’s a big but,
because it is really different when you are already in a situation wherein you will truly discern the
client’s agony, the full support of significant others, because of such condition.

Choosing this case is a great advantage for me as a nursing student for a fact that it will
benefit me in terms of information, performing procedures accurately, giving medications. In short, it
enhances my skills in the area.
Prior to this case, it is a good opportunity as well that it has been assigned to me surely
because it widened my understanding on how this certain condition affects the life of each client.

This case became the preference for me because of it encompasses medical-surgical

nursing concepts in which I able to relate to. In the case of my client, he manifested Fluid and
Electrolyte imbalances which are part of the basic concepts necessary for further comprehension of
most disease conditions that I may encounter in the clinical setting. Furthermore, the case caught
my interest because of the disease complications which I consider a challenging first-hand
experience.
II. CLIENT’S PROFILE

1. Health Perception and Health Management Pattern

Chief complaint:
Patient was admitted due to shortness of breath and edema formation. Last admission was
March 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 November 2010, the patient manifested signs 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 went
home 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 a huge
amount of money. When they asked for any assurance for the blurredness to be relieved after
undergoing the surgery, they were given the assurance which made them decide not to take the risk.
Few weeks later the right eye became totally blind and the left eye had an angular blurredness.
When they went back to the specialist for the third time, it was found out that the left eye had a blood
clot covering the pupil.
Patient was diagnosed with CKD last March 2011.
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 Calcium
Carbonate, but did not comply with the other drug which is Ketosteril.

Vital Signs Upon assessment, the following data was obtained from Patient X
Blood pressure = 140/90mmHg
` Axillary temperature = 36.8 0C;
Pulse rate = 89 beats per minute;
Respiratory rate = 20 counts per minute.

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.
1. Nutrition and Metabolic Pattern

Eating pattern:
The patient has fair-good appetite for eating. There are times that he could consume a whole
share of his diet but there 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, and diabetic diet. No intravenous fluid was used.

PHYSICAL ASSESSMENT:

MOUTH: Lips are pale, and dry so as his mucosa. His tongue is midline and dental caries noted, with
missing teeth, and pale gums.
PHARYNX: 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
HEAD: Head is normocephalic, with symmetrical facial movements. Hair is fine, and scalp is
clean.
EYES: Eyelids are symmetrical. Periorbital region is on edema, while conjunctiva is pale.
Sclera is icteric. Pupils have sluggish reaction to light, having a size of 4mm on the right eye
and 3mm on the left. Peripheral vision is decreased/limited.
EARS: External Pinnae is normoset. No ear discharges tympanic membrane intact. Gross
hearing is intact
NOSE: Nasal septum is midline, mucosa is pale, and both nasal openings are patent, with no
discharges and non tender sinuses

Other pertinent data:

Presence of wound dressing on right neck due to Intra-jugular catheter insertion for his
dialysis.
 2. 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. With normoactive
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.

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 Apical rate reaches
up to 89 and arrhythmia is noted. Heart sounds are faint and irregular. The peripheral pulses are
asymmetrical and faint.

Respiratory status:
Breathing pattern is irregular. Wheezes heard at left lung, ronchi and crackles at the right.
The Anteroposterior Lateral ratio is 1:2 and the lung expansion is symmetrical. Tactile fremitus
is also symmetrical. The lungs are resonant when the back is percussed. The patient has a
productive cough with white sputum.
Patient has Oxygen inhalation via nasal cannula, regulated at 4 LPM.
Activities of daily Living
Range of motion symmetrical, with staggering gait.

5. Cognitive – Perceptual Pattern

Level of consciousness:
Patient is conscious and oriented to time, place, and person.
Patient’s emotional state is anxious.
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.

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 sleep disturbances.

7. Self-perception and Self-concept Pattern

The patient is anxious about his condition, and oftentimes verbalizes that he doesn’t
understand his feeling.

8. Role – Relationship Pattern

Marital status: Patient is married, with one child.

Age and health of significant other: Spouse is 50 years old and in good condition.
Patient’s family has a history of diabetes on the maternal side.
Living together with family, but does not have any occupation. Patient’s family is worried for
patient’s condition, and is worried regarding financial support.
Financial support system would be the wife’s income.

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 monthly testicular
examination.
Penis: No discharges noted, and no lesions
Scrotum: patient manifested hydrocele in the scrotum

10. Coping – Stress Tolerance Pattern

One of the recent stressful situations that complicate his feelings is financial crisis of the
family. His wife took her advance pay from work to support 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. His family continues to pray and ask for guidance
from God to help them pass through this difficult time that they are having. They used to go to church
every Sunday, but were not able to comply with it since patient’s hospitalization.
III. ANATOMY AND PHYSIOLOGY
The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is
both an endocrine gland
producing several
important hormones,
including insulin,
glucagon, and
somatostatin, as well as an
exocrine gland,
secreting pancreatic juice
containing digestive
enzymes that pass to the
small intestine. These
enzymes help to further
breakdown the
carbohydrates, protein, and fat
in the chyme.

Histology
Under a microscope, stained sections of the pancreas reveal two different types of
parenchymal tissue.[2] Lightly staining clusters of cells are called islets of Langerhans, which
produce hormones that underlie the endocrine functions of the pancreas. Darker staining cells form
acini connected to ducts. Acinar cells belong to the exocrine pancreas and secrete digestive
enzymes into the gut via a system of ducts.
Structure Appearance Function
Islets of Lightly staining, large, Hormone production and secretion
Langerhans spherical clusters (endocrine pancreas)
Pancreatic Darker staining, small, Digestive enzyme production and
acini berry-like clusters secretion (exocrine pancreas)

Function
The pancreas is a dual-function gland, having features of both endocrine and exocrine
glands.
 Endocrine
Main article: Endocrine pancreas
[3]
The part of the pancreas with endocrine function is made up of approximately a million cell
clusters called islets of Langerhans. Four main cell types exist in the islets. They are relatively
difficult to distinguish using standard staining techniques, but they can be classified by their
secretion: α cells secrete glucagon (increase Glucose in blood), β cells secrete insulin (decrease
Glucose in blood), δ cells secrete somatostatin (regulates/stops α and β cells), and PP cells secrete
pancreatic polypeptide.[4]
The islets are a compact collection of endocrine cells arranged in clusters and cords and are
crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of
endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with
blood vessels, by either cytoplasmic processes or by direct apposition. According to the volume The
Body, by Alan E. Nourse,[5] the islets are "busily manufacturing their hormone and generally
disregarding the pancreatic cells all around them, as though they were located in some completely
different part of the body."

Regulation
The pancreas receives regulatory innervation via hormones in the blood and through the
autonomic nervous system. These two inputs regulate the secretory activity of the pancreas.
Sympathetic (adrenergic) Parasympathetic (muscarinic)
α2: decreases secretion from beta cells, M3[6] increases stimulation of alpha
increases secretion from alpha cells cells and beta cells

Position
It lays in the epigastrium & left hypochondrium areas of the abdomen
Parts
It consists of:
Head: Lies within the concavity of the duodenum
Uncinate process: emerges from the lower part of head & lies deep to superior mesenteric
vessels
Neck: The constricted part between the head and the body
Body: It lies behind stomach
Tail: It is the left end of the pancreas. It lies in contact with the spleen and runs in the
lienorenal ligament
Blood Supply
Arterial Supply
Superior pancreaticoduodenal artery from gastroduodenal artery
Inferior pancreaticoduodenal artery from superior mesenteric artery
Both run in the groove between the pancreas & duodenum & supply the head of pancreas.
Systemic circulation
Systemic circulation is the portion of the cardiovascular system which transports oxygenated blood
away from the heart, to the rest of the body, and returns oxygen-depleted blood back to the heart.
Systemic circulation is, distance-wise, much longer than pulmonary circulation, transporting blood to
every part of the body.

Coronary circulation
The coronary circulatory system provides a blood supply to the heart.

Renal System

The kidneys are essentially regulatory organs which

maintain the volume and composition of body fluid by
filtration of the blood and selective reabsorption or
secretion of filtered solutes.

The kidneys are retroperitoneal organs (is located

behind the peritoneum) situated on the posterior wall of the
abdomen on each side of the vertebral column, at about the
level of the twelfth rib. The left kidney is lightly higher in the
abdomen than the right, due to the presence of the liver
pushing the right kidney down.
The kidneys take their blood supply directly from the
aorta via the renal arteries; blood is returned to the inferior vena cava via the renal veins. Urine (the
filtered product containing waste materials and water) excreted from the kidneys passes down the
fibromuscular ureters and collects in the bladder. The bladder muscle (the detrusor muscle) is
capable of distending to accept urine without increasing the pressure inside; this means that large
volumes can be collected (700-1000ml) without high-pressure damage to the renal system
occuring. When urine is passed, the urethral sphincter at the base of the bladder relaxes, the
detrusor contracts, and urine is voided via the urethra.

Structure of the kidney

Kidneys
The kidneys regulate the volume and concentration of fluids in the body by producing urine.
Urine is produced in a process called glomerular filtration, which is the removal of waste products,
minerals, and water from the blood. The kidneys maintain the volume and concentration of urine by
filtering waste products and reabsorbing useful substances and water from the blood.
 On sectioning, the kidney has a pale outer
region- the cortex- and a darker inner region- the
medulla.The medulla is divided into 8-18 conical
regions, called the renal pyramids; the base of
each pyramid starts at the corticomedullary
border, and the apex ends in the renal papilla
which merges to form the renal pelvis and then
on to form the ureter. In humans, the renal pelvis
is divided into two or three spaces -the major calyces-
which in turn divide into further minor calyces. The walls
of the calyces, pelvis and ureters are lined with smooth
muscle that can contract to force urine towards the bladder by peristalisis.
The cortex and the medulla are made up of nephrons; these are the functional units of the
kidney, and each kidney contains about 1.3 million of them.

The kidneys also perform the following functions:

 Detoxify harmful substances (e.g., free radicals, drugs)
 Increase the absorption of calcium by producing calcitriol (form of vitamin D)
 Produce erythropoietin (hormone that stimulates red blood cell production in the bone
 marrow)
 Secrete renin (hormone that regulates blood pressure and electrolyte balance)
The kidneys are a pair of bean-shaped organs located below the ribs near the middle of the
back.
They are protected by three layers of connective tissue: the renal fascia (fibrous membrane)
surrounds the kidney and binds the organ to the abdominal wall; the adipose capsule (layer of fat)
cushions the kidney; and the renal capsule (fibrous sac) surrounds the kidney and protects it from
trauma and infection.

Renal Artery
The renal
artery enters the
kidney and the
renal vein
emerges from the
kidney at an indentation in the middle of the organ called the hilum. The renal artery supplies
oxygen and blood to the kidney. Blood flows from the kidney through the renal vein after waste
products have been removed.
Formation and Elimination of Urine

The formation of urine occurs in the basic units of the kidney, called nephrons. Each human
kidney contains over 1 million nephrons. Nephrons consist of a network of capillaries (called a
glomerulus), a renal tubule, and a membrane that surrounds the glomerulus and functions as a filter
(called Bowman's capsule). The glomeruli are where urine production begins. Urine formation
occurs in the renal tubules, which travel from the outer tissue of the kidney (called the cortex), to the
inner tissue (called the medulla), and return to the cortex.
Extensions of the cortex project into the medulla and divide the tissue into renal pyramids.
The renal pyramids extend into funnel-like extensions (called calyces), where the collection of urine
occurs. Minor calyces merge to form major calyces and major calyces merge to form the renal
pelvis, the upper portion of the ureter.
Each section of the renal tubule performs a different function. As the tube leads away from
Bowman's capsule into the cortex, it forms the proximal convoluted (highly coiled) tubule. In this
section, waste products and toxic substances (e.g., ammonia, nicotine) are forced out of the blood
through a permeable membrane and useful substances (e.g., glucose, amino acids, vitamins,
minerals) are reabsorbed.
Urine then travels through the loop of Henle, a long U-shaped extension of the proximal
convoluted tubule. It consists of a descending limb and an ascending limb. Some sections of the
loop are permeable to water and impermeable to substances in the urine (e.g., salt, ammonia), and
some sections are impermeable to water and permeable to other substances.
Hormones
The hypothalamus in the brain detects the level of substances in the blood and controls the
secretion of hormones. Antidiuretic hormone, aldosterone, and atrial natriuretic factor are hormones
that change the permeability of the distal convoluted tubule and the collecting tubule, regulating
urine volume and helping to maintain blood pressure.
For example, when water content in the blood is low (called dehydration), the secretion of
antidiuretic hormone (ADH) increases and the kidneys reabsorb more water. This increases the
concentration of the urine and decreases urine output. When water content in the blood is high,
ADH production ceases and the kidneys reabsorb less water. This decreases the concentration of
the urine and increases urine output.

BUN and Creatinine

The concentration in the blood (blood level) of blood urea nitrogen (BUN), known as urea,
and creatinine (Cr) can be measured by routine laboratory tests. BUN and creatinine levels indicate
the general function of the kidneys. BUN is a metabolic by-product of protein-rich food such as
meat, poultry, and certain vegetables. BUN is filtered out of the blood by the kidneys and excreted
in the urine. Creatinine is continuously generated by normal cell metabolism within the muscles.
Creatinine is also filtered out of the blood by the kidneys and excreted in the urine.
The amounts of BUN and creatinine in the blood are equal to the amount excreted by the
kidneys. The blood levels of BUN and Cr remain unchanged unless there is sudden deterioration of
renal (i.e., kidney) function. If the kidneys are suddenly unable to function, BUN and Creatinine
increase daily. This condition is known as acute renal failure. Chronic renal failure is a condition
distinguished by a gradual increase in BUN and Cr over a long period of time.

IV. PATHOPHYSIOLOGY
 The underlying pathophysiology defect in type 2 diabetes is characterized by the following
three disorders (1) peripheral resistance to insulin, especially in muscles cells: (2) increased
production of glucose by the liver, and (3) altered pancreatic secretion.
Increased tissue resistance to insulin generally occurs first and eventually followed by
impaired insulin secretions. The pancreas produces insulin, yet insulin resistance prevents its
proper use at the cellular level. Glucose cannot enter target cells and accumulates in the blood
streams, resulting in hyperglycemia. The high blood glucose levels often stimulate an increase in
insulin production by the pancreas: thus. Type 2 diabetic individuals often have excessive insulin
production (hyperinsulinemia).
Insulin resistance refers to tissue sensitivity to insulin. Intracellular reaction are diminished, making
insulin less effective at stimulating glucose uptake by the tissues and regulating glucose release by
the liver.
If blood glucose levels are elevated consistently for a significant period of time, the kidney’s
filtration mechanism is stressed, allowing blood proteins to leak into the urine. As a result, the
pressure in the blood vessels of the kidney increases. It is thought that the elevated pressure
serves as the stimulus the level of nephropathy.
The earliest detectable change in the course of diabetic nephropathy is a thickening in the
glomerulus. At this stage, the kidney may start allowing more albumin (protein) than normal in the
urine, and this can be detected by sensitive tests for albumin.
As diabetic nephropathy progresses, increasing numbers of glomeruli are destroyed. Now the
amounts of albumin being excreted in the urine increases, and may be detected by ordinary
urinalysis techniques. At this stage, a kidney biopsy clearly shows diabetic nephropathy and
eventually leads to chronic renal failure.

V. LABORATORY AND DIAGNOSTIC FINDINGS

Complete Blood Count (CBC)
A complete blood count (CBC) gives important information about the kinds and numbers of cells in
the blood, especially red blood cells , white blood cells , and platelets. A CBC helps your health
professional check any symptoms, such as weakness, fatigue, or bruising, you may have. A CBC
also helps him or her diagnose conditions, such as anemia, infection, and many other disorders.
A CBC test usually includes:
• White blood cell (WBC, leukocyte) count. White blood cells protect the body against
infection. If an infection develops, white blood cells attack and destroy the bacteria, virus, or
other organism causing it. White blood cells are bigger than red blood cells but fewer in
number. When a person has a bacterial infection, the number of white cells rises very quickly.
The number of white blood cells is sometimes used to find an infection or to see how the
body is dealing with cancer treatment.
• White blood cell types (WBC differential). The major types of white blood cells are
neutrophils, lymphocytes, monocytes, eosinophils, and basophils. Immature neutrophils,
called band neutrophils, are also part of this test. Each type of cell plays a different role in
protecting the body. The numbers of each one of these types of white blood cells give
important information about the immune system. Too many or too few of the different types of
white blood cells can help find an infection, an allergic or toxic reaction to medicines or
chemicals, and many conditions, such as leukemia.
• Red blood cell (RBC) count. Red blood cells carry oxygen from the lungs to the rest of the
body. They also carry carbon dioxide back to the lungs so it can be exhaled. If the RBC count
is low (anemia), the body may not be getting the oxygen it needs. If the count is too high (a
condition called polycythemia), there is a chance that the red blood cells will clump together
and block tiny blood vessels (capillaries). This also makes it hard for your red blood cells to
carry oxygen.
• Hematocrit (HCT, packed cell volume, PCV). This test measures the amount of space
(volume) red blood cells take up in the blood. The value is given as a percentage of red blood
cells in a volume of blood. For example, a hematocrit of 38 means that 38% of the blood's
volume is made of red blood cells. Hematocrit and hemoglobin values are the two major tests
that show if anemia or polycythemia is present.
• Hemoglobin (Hgb). The hemoglobin molecule fills up the red blood cells. It carries oxygen
and gives the blood cell its red color. The hemoglobin test measures the amount of
hemoglobin in blood and is a good measure of the blood's ability to carry oxygen throughout
the body.
• Red blood cell indices. There are three red blood cell indices: mean corpuscular volume
(MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin
concentration (MCHC). They are measured by a machine and their values come from other
 measurements in a CBC. The MCV shows the size of the red blood cells. The MCH value is
the amount of hemoglobin in an average red blood cell. The MCHC measures the
concentration of hemoglobin in an average red blood cell. These numbers help in the
diagnosis of different types of anemia. Red cell distribution width (RDW) can also be
measured which shows if the cells are all the same or different sizes or shapes.
• Platelet (thrombocyte) count. Platelets (thrombocytes) are the smallest type of blood cell.
They are important in blood clotting. When bleeding occurs, the platelets swell, clump
together, and form a sticky plug that helps stop the bleeding. If there are too few platelets,
uncontrolled bleeding may be a problem. If there are too many platelets, there is a chance of
a blood clot forming in a blood vessel. Also, platelets may be involved in hardening of the
arteries (atherosclerosis).
• Mean platelet volume (MPV). Mean platelet volume measures the average amount (volume)
of platelets. Mean platelet volume is used along with platelet count to diagnose some
diseases. If the platelet count is normal, the mean platelet volume can still be too high or too
low.

COMPLETE BLOOD COUNT

March 04, 2011
NORMAL
TEST RESULT UNIT VALUES INTERPRETATIONS
10ˆ3/u
WBC 11.5 L 5.0-10 HIGH
10ˆ6/u
RBC 3.2 L 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
BASOPHIL 0.1 % 1.0-2.0 NORMAL
10ˆ3/u
PLATELET 200 L 150-450 NORMAL

March 06, 2011

NORMAL
TEST RESULT UNIT VALUES INTERPRETATIONS
10ˆ3/u
WBC 11.9 L 5.0-10 HIGH
10ˆ6/u
RBC 3.11 L 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
BASOPHIL 0 % 1.0-2.0 LOW
10ˆ3/u
PLATELET 200 L 150-450 NORMAL

March 08, 2011

TEST RESULT UNIT NORMAL VALUES

10ˆ3/u
WBC 9.6 L 5.0-10
10ˆ6/u
RBC 3.91 L 4.2-5.4
HGB 10.7 g/dl 12.0-16
HCT 34.8 % 37-47
DIFF. COUNT
LYMPHOCYTE 6.2 % 17.4-48.2
NEUTROPHIL 84.1 % 43.4-76.2
MONOCYTE 0.8 % 1.0-3.0
EUSINOPHIL 0 % 0.0-2.0
BASOPHIL 0 % 1.0-2.0
10ˆ3/u
PLATELET 200 L 150-450

BLOOD CHEMISTRY

March 04, 2011

LAB TEST RESULT NORMALVALUES INTERPRETATIONS
BUN 100.6 4.6-23.4 HIGH
CREATININE 6.76 0.6-1.2 HIGH
SODIUM 142.27 135-148 NORMAL
CALCIUM 5.19 8.1-10.4 LOW
POTASSIUM 5.12 3.5-5.3 NORMAL
ALBUMIN 2.89 3.8-5.1 LOW

March 06, 2011

LAB TEST RESULT NORMALVALUES INTERPRETATIONS
BUN 82.7 4.5-23.5 HIGH
URIC 7.9 3.50-7.0 HIGH
SODIUM 142.9 134-149 NORMAL
MAGNESIUM 1.02 2.4-3.6 LOW
CREATININE 4.7 0.59-1.21 HIGH
POTASSIUM 5 3.4-5.4 NORMAL
CALCIUM 4.52 8.2-10.5 LOW
PHOSPHORUS 5.36 2.4-5.1 HIGH

VI. DRUG STUDY

 VII. NURSING CARE PLAN

VIII. HEALTH TEACHING AND DISCHARGE PLAN

Medications

• Explain the purpose, dosage, schedule, and route of administration of any prescribed drug,
as well as side effects to report to the physician or nurse.
 • Stress the importance of taking medications on schedule; assist the patient to schedule
taking medication on schedule; assist the patient to schedule taking medications to achieve
the peak effect.
• Review drug regimen, possible side effects.
• Note for any adverse effects and drug side effects.

Exercise

• Exercise at least 10-15 minutes a day for good blood circulation and to use excess glucose
in the body to lower down blood glucose level.
• Walking can also be a good exercise.

Treatment
• Advice patient to avoid stress related factors.

Homecare

• Give the patient verbal and written instructions as to how and when to take her medications.
• Encourage patient to eat healthy foods like vegetables and fruits and less meat. Avoid foods
that contain a lot of preservatives like canned goods and processes foods.
• Encourage avoidance of drinking too much alcohol. If ever she is already under the influence
of alcohol, advise not to drive any auto mobiles to avoid accident.

Outpatient

• Stress the importance of follow-up visits. Make sure the patient has the necessary names
and telephone numbers to contact to, whenever needed.
• Stress the importance of any prescribed follow-up care, including laboratory tests.

Diet

• Encourage patient to eat healthy foods like vegetables and fruits and less meat.
• Avoid dark colored foods and that contains a lot of preservatives like canned goods and
processed foods.
• Instruct the patient to eat foods that are high in protein to promote faster wound healing.
• Proper diet is needed to maintain an ideal weight and to avoid future illnesses.
Spiritual
• Encourage patient to pray always to be thankful to God for his goodness.

IX. LEARNING EXPERIENCE

As RLE-40 student, this is my first time to expose in NMMC Medical Ward. At first I am
so startled and shocked because of the different patients with different cases, thus gave me a hard
time to adjust.
 On making my case study, I’ve learned how to be patient, to persevere and to closely interact
with my patient. This is also the application of the knowledge I gained throughout this rotation.

With the sense of appreciation, I am very thankful for having this opportunity of
widening my knowledge and skills. All the things I’ve learned from gathering all data up to finalizing
the study, I considered them significant for this profession. I’ve also learned important points from
my clinical instructor, the area, and the staff, which I’m very thankful of. Such learning would be of
great use as being an aspiring nurse.

X. REFERENCES

Websites:
http://nursingcrib.com/case-study/diabetes-mellitus-case-study/
http://www.scribd.com/doc/19465471/Case-Study-on-Chronic-Kidney-Disease
http://www.nlm.nih.gov/medlineplus/ency/article/003263.htm
http://www.nhlbi.nih.gov/health/dci/Diseases
http://www.webmd.com/a-to-z-guides/
http://www.answers.com/topic/integumentary-system
http://en.wikipedia.org/wiki/Circulatory_system
http:// www.nursingblogspot.com
http:// www.evolve.elsevier.com/black/medsurg

BOOKS:
● Nursing Drug Guide 2007 Lippincott Any M. Karch
● Brunner and Suddarth textbook of Medical Surgical Nursing
● Nurse' Pocket Guide, Diagnoses, Prioritized Interventions, and Rationales
● Nursing Health Assessment by: Patricia M. Dillon