Chronic Kidney Disease

Presented to:

DIVISION OF NURSING EDUCATION AND TRAINING

NURSING SERVICE

PHILIPPINE GENERAL HOSPITAL

September 16, 2011

CASE STUDY

presented by:

Joshua Alonzo, RN
QUIRINO MEMORIAL MEDICAL CENTER

A. CLIENT PROFILE Name: Patient RC Age: 36 year old Gender: Male Status: Single

Religious Affiliation: Roman Catholic Address: Sampaloc, Manila Date Admitted: August 28, 2011 Room and Bed#: Medicine Ward Attending Physician: Dr. Geronimo Working Diagnosis: Chronic Kidney Disease Stage V secondary to DM Type 2

B. CHIEF COMPLAINT: Difficulty of Breathing C. BRIEF HISTORY OF PRESENT ILLNESS Few hours prior to admission, the patient started to complain difficulty of breathing, restlessness and signs of generalized edema on both upper and lower extremities. Associated with ascites, which prompted to seek consult hence, admission. D. PAST MEDICAL HISTORY The patient is a regularly having his Hemodialysis at UP-PGH renal unit since 2007 and known diabetic for 4 years. Patient has been maintained on Ferrous Sulfate, Calcium Carbonate, Metformin and Amlodipine, with regular follow-up check-up c/o UP-PGH renal service.

E. PATTERNS OF FUNCTIONING

ADL 1. NUTRITION

Before Hospitalization The client eats 3 x a day on Low Salt, Low Fat, DM diet and his oral intake was limited to 1L per day. Sometimes, he doesnt follow the diet due some circumstances.

During Hospitalization Patient is in poor appetite.

Interpretation and Analysis Due to her pathologic condition the patient was placed on Low Low Salt, Low Fat, DM Diet was Salt, Low Fat , DM diet with ordered. fluid restrictions so that it will Fluid restrictions were ordered not aggravate the disease due to generalized edema and process and will not, somehow, compromised the daily increase in creatinine. nutritional requirements she needs. Intake strictly monitored.

2. ELIMINATION

The client urinates less Clients move his bowel once a often but he regularly day. His urine output is smaller moves his bowel once a amount than usual. day. Urine output was strictly monitored.

Strictly monitoring of urine output will help to control accumulation of fluid in interstitial tissue.

3. ACTIVITY

The client is ambulatory, he He cant walk because of easy can walk and run, until he fatigability. His relatives assist felt increase in weight him when moving around. associated with difficulty in breathing .

The patient cannot perform normal activities unless with assistance. He gets easily tired because of excess fluid in his body.

ADL 4. HYGIENE

Before Hospitalization During Hospitalization He takes a bath, brushes He did brush his teeth, dressed his teeth and dresses himself with assistance. alone.

Interpretation and Analysis Although hes in the hospital he still maintained cleanliness and good hygiene.

5. SUBSTANCE USE

He drinks her prescribed The patient complied with his The relatives doesnt complied home medication prescribed therapeutic regimen. religiously to her drug regimen everyday. Sometimes he thus complications occur. tend to forget taking it. She normally sleeps continuously for 6 to 8 hours. However, when he felt increase in weight and sometimes Shortness of breath he no longer have a good sleep. After therapeutic regimen was given and Hemodialysis started he sleeps comfortably and continuously. Too much water in his body alters his sleeping pattern. However, this was resolved when diuretics medication and Hemodialysis started.

6. SLEEP AND REST

F. RATIONALE FOR CHOOSING THE CASE The author chose this case because he was my first patient on my first day of training. He is very cooperative and kind. His relatives were very supportive and I was wondering what he has done why he had this disease. He was a regular OPD patient in renal unit having a regular Hemodialysis. Eventually, he was admitted due to difficulty of breathing and an obvious generalized edema. I saw him and I was the one assigned for his Hemodialysis. Aside, it is a unique case a patient with known diabetic leads to Chronic Kidney Disease Stage V.

G. PHYSICAL ASSESSMENT (upon admission) Area Assessed General Survey Findings Patient is awake, coherent, slightly pale, in cardio respiratory distress with the following vital signs: BP: 180/100; CR: 80; RR: 25; Temp: 36.5; Weight: 70 kg; Height: 5 ft CBG = 250 mg/dL Analysis and Interpretation

With loss of kidney function, there is an accumulation of water; waste; and toxic substances, in the body, that are normally excreted by the kidney. Loss of kidney function also causes other problems such as anemia, high blood pressure, acidosis (excessive acidity of body fluids), and disorders of cholesterol and fatty acids, and bone disease.

http://www.emedicinehealth.com/chronic_kidney_disease/ar

ticle_em.htm

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.

http://nursingdepartment.blogspot.com/2009/03/pathophysi ology-of-diabetes-milletus.html

Head, Eyes, Ears, Nose, Neck, Throat Chest / Lungs

Pink conjunctiva, anicteric sclera, no Normal nasoaural discharge, no tonsillopharyngeal congestion, no neck vein engorgement. Symmetrical chest expansion but breathing Trouble catching your breath can be related is somewhat deep, to the kidneys in two ways. First, extra fluid in Tachypneic, Shortness of Breath, the body can build up in the lungs. And (+) Crackles on both lower lung fields. second, anemia (a shortage of oxygen-carrying red blood cells) can leave your body oxygenstarved and short of breath.
http://www.lifeoptions.org/kidneyinfo/ckdinfo.php?page=4

Heart

Adynamic precordium, apex beat at 5th intercostal space left mid clavicular line, regular rhythm, distinct S1 and S2, no murmurs, no gallops. Hypertensive

CKD can lead to salt retention and subsequent volume overload. This may or may not be accompanied by swelling (edema) along with increased blood pressure. In addition, failing kidneys appear to trigger increased activity of the sympathetic nervous system, causing something like an adrenaline surge. More advanced CKD can also lead to low blood count or anemia. The treatment may help to produce hypertension, depending on the resultant rise in the blood count.
http://www.aakp.org/aakp-library/hypertension-and-

c-k-d/

Abdomen

Flat, normoactive bowel sounds, soft, no Normal

Extremities

inflammation. Pink nail beds, no cyanosis, no clubbing, Rashes, Dry skin, Generalized edema

Failing kidneys don't remove extra fluid, which builds up in your body causing swelling in the legs, ankles, feet, face, and/or hands. Kidneys remove wastes from the bloodstream. When the kidneys fail, the buildup of wastes in your blood can cause severe itching.
http://www.lifeoptions.org/kidneyinfo/ckdinfo.php? page=4

Rectal

No skin tags, no fissures, good sphincter tone.

Normal

H. LABORATORY AND DIAGNOSTIC EXAMINATION Test Name WBC RBC Normal Values 5 10 4.0 6.0 8/28 11.5 3.5 8/30 8.5 4.5 9/1 9 3.75 9/5 9.5 4.10

Hemoglob 120 - 170 110 120 125 140 in Hematocri 0.38 0.48 0.333 0.389 0.412 0.415 t Platelet 150 - 450 270 280 284 290 Ct. Bun 2.9 9.3 50.5 60.80 30.50 35.10 Crea Ca Na K Cl 39 - 91 2.15 2.50 136 - 144 3.6 5.1 101 - 111 971 1.5 137 4.5 100 1023 1.90 141 3.5 110 885 1.71 140 4.5 105 902 1.99 142 4.1 111

HEPATITIS PROFILE Date: 8/26/11 URINALYSIS Date: 8/26/11

Result: Non reactive Result: ++++ Albumin and Ketones

I. IMPRESSION / DIAGNOSIS Chronic Kidney Disease stage IV secondary to DM type2

J. PATHOPHYSIOLOGY

Type 2 Diabetes

Peripheral resistance to insulin

Increased production of glucose by the liver Hyperglycem ia

Altered pancreatic secretions

Stress Kidney Filtration Diabetic Nepropathy progresses Thickening of Glomerulus Increased number of Chronic Kidney Disease

Protenuria Hypertension Chronic Protenuria Hypertension

Decreased Erythropoeitin Decreased RBC Anemia, Tachypnea, Fatigue

Fails to remove extra fluid and waste. Build up waste in blood Skin rash / Itching

Fluids build up in upper and lower extremities, Lungs Difficulty of Breathing SOB

K. NURSING CARE PLAN Nursing Problems/ Cues Evaluation Ineffective Airway Clearance related to fluid accumulatio n in the SCIENTIFIC ETIOLOGY Immediate: Inadequate ventilation Analysis Goal/ Objectives Nursing Rationale SEVERE OCCURRENCE OF LESIONS Interventions + CASSEOUS NECROSIS Short term Goal: After 30 mins. of nursing interventions, GOAL PARTIALLY MET as evidence by: Normal respiratory rate Verbalized relief

Short term Goal: After 30 mins. of nursing interventions, the patients will establish

INDEPENDENT 1. Establish rapport 2. Inform and explain to the 1. To gain clients cooperation. 2. To decrease anxiety and

lungs

Subjective: Nahirapan akong huminga Root Cause: as Disease verbalized by the Condition patient. Objective: RR = 25 cpm Shortness of breath With crackles on both lung field upon auscultatio n

Intermediat e: reduced Oxygen Transport to the cell

normal and effective airway clearance as evidenced by: Normal respiratory rate Verbalization of relief

patient before initiating procedures 3. Auscultate anterior and posterior chest for increased, decreased or absent ventilation and presence of adventitious sounds. Assess respiration, note quality, rate, pattern, depth, nasal flaring, use accessory muscles.

promotes cooperation 3. Allows for early detection and correction of abnormalities. Diminished breath sounds may reflect atelectasis.Rhonchi, wheezes indicate accumulation of secretions/inability to clear airways that may lead to use of accessory muscles and increased work of breathing. 4. Open or maintain open airway in at rest. When the client is in semi-Fowlers position, gravity pulls the diaphragm downward allowing greater lung expansion and lung ventilation 5. Maximal ventilation may open atelectatic areas and promote movement of secretions into larger airways for expectoration 6. Position of comfort make it easier for the patient to breath

4. Position head midline with flexion appropriate. Position client appropriately. (Semi-Fowlers) Elevate HOB / change position every 2 hours and PRN. 5. Encourage and assist in slow deep breathing or purse-lip

Long term Goal: GOAL MET Client is able to maintain airway patency as evidenced by:

technique. 6. Encourage position of comfort. Reposition client frequently if patient is immobile. COLLABORATI VE 7. Administer humidified air and oxygen 8. Administer Medications as ordered: Furosemide 20mg/IV Clear breath sounds Normal respiratory rate 7. Prevents drying of mucous membranes; To prevent hypoxia. 8. Loop Diuretics monitor BP

Long term Goal: Client is able to maintain airway patency.

Nursing Problems/ CuesAnalysisGoal/ ObjectivesNursing InterventionsRationaleEvaluationShort term Goal: L. EVALUATION The effectiveness of long-term goal was partially met because of lack to time to monitor patient. I evaluate the care we give by means of time frame and patients condition if it is achievable. Our source of satisfaction is the patient only because the patient is coherent and cooperative. I have Learned so many thing in the disease itself and its complication and how to prioritized my nursing care plan To improve our nursing care, nurse should be knowledgeable and know how to do deal with kind of diseases.

References: F.A. Davis's Nursing Care Plan, Smeltzer, Suzzane. Bare, Brenda. Medical Surgical Nursing 10th Edition Black, Joyce M., Hawks, Jane, and Keene, Annabelle M. Medical-Surgical Nursing. 7th edition. Kozier, et. Al. Fundamentals of nursing
http://www.emedicinehealth.com/chronic_kidney_disease/article_em.htm http://nursingdepartment.blogspot.com/2009/03/pathophysiology-of-diabetes-milletus.html http://www.aakp.org/aakp-library/hypertension-and-c-k-d/

After 30 mins. of nursing interventions, GOAL PARTIALLY MET as evidence by: Normal BP Verbalized relief

 Long term Goal: GOAL MET Client is able to maintain comfort evidenced by: Normal BP Edema, Itchiness lessened 1. To gain clients cooperation. 2. To decrease anxiety and promotes cooperation 3. Allows for early detection and correction of abnormalities. 4. Diverting tactics is provided so that the patient will not be able to focus on his discomfort; 5. Position of comfort make it easier for the patient to breath and relax. 6. Loop Diuretics monitor BP; Informed patient the side effects of medicine before giving INDEPENDENT 1. Establish rapport 2. Inform and explain to the patient before initiating procedures 3. Monitor BP taking

4. Provide patient a diverting tactics. 5. Encourage position of comfort. Reposition client frequently if patient is immobile. COLLABORATIVE

6. Administer Medications as ordered: Furosemide 20mg/IV Loratidine 10mg/tab Short term Goal: After 30 mins. of nursing interventions, the patients will establish comfort as evidenced by: Normal BP Verbalization of relief Long term Goal: Client is able to maintain comfort. SCIENTIFIC ETIOLOGY Immediate: Impaired Comfort Intermediate: Accumulation of Extra fluid in interstitial tissue, waste in the blood and decreased RBC Root Cause: Disease process

Impaired Comfort related fatigue, fluid retention and anemia Subjective: Napapagod ako dahil sa manas ko as verbalized by the patient Objective: With edema on both upper and lower extremities Pruritus BP=180/100