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 Stage 5 CKD is also called established chronic kidney disease and is synonymous with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).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.

Patient Data Profile Demographic Data Name: Mrs. X Age: 50 y/o Sex: Female Civil Status: Married Religion: Roman Catholic Birth Place: Pampanga Admission Data Date and Time of Admission: January 2, 2012 Attending Physician: Dr. Catungal Admission Diagnosis: Chronic Kidney Disease probably 2 to hypertension Medical History 2002 Kidney transplant Family Medical History Fathers Side: hypertension Mothers Side: hypertension Past Medical History The patient was diabetic 10 years and has secondary hypertension. By the year 1999 she was diagnosed with chronic kidney disease, and she was undergoing Hemodialysis since then. This made her decide to have a kidney transplant in 2002. Present Medical History Four days prior to admission the patient was experiencing mild difficulty of breathing and reports of flank pain. The patient was admitted last January 2, 2012 complaining of Difficulty of Breathing.

Physical Assessment Patient was conscious, coherent, afebrile, pale, has normal rate and rhythm of heartbeats. Her abdomen is flabby, soft, no tenderness noted, normal abdominal bowel sounds. No cyanosis was noted, has full and equal pulses, noted fistula on right forearm. Noted retractions, and signs of difficulty of breathing, crackles noted upon auscultation, patient was also noted to have signs of uremic frost.

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 (see below) 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. 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 pH (i.e., level of acidity or alkalinity) 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. Parts and Function: Renal Vein This has a large diameter and a thin wall. It carries blood away from the kidney and back to the right hand side of the heart. Blood in the kidney has had all its urea removed. Urea is produced by your liver to get rid of excess amino-acids. Blood in the renal vein also has exactly the right amount of water and salts. This is because the kidney gets rid of excess water and salts. The kidney is controlled by the brain. A hormone in our blood called Anti-Diuretic Hormone (ADH for short) is used to control exactly how much water is excreted. Renal Artery This blood vessel supplies blood to the kidney from the left hand side of the heart. This blood must contain glucose and oxygen because the kidney has to work hard producing urine. Blood in the renal artery must have sufficient pressure or the kidney will not be able to filter the blood. Blood supplied to the kidney contains a toxic product called urea which must be removed from the blood. It may have too much salt and too much water. The kidney removes these excess materials; that is its function. Pelvis This is the region of the kidney where urine collects. Ureter the ureter carries the urine down to the bladder. Medulla The medulla is the inside part of the kidney. This is where the amount of salt and water in your urine is controlled. It consists of billions of loops of Henl. These work very hard pumping sodium ions. ADH makes the loops work harder to pump more sodium ions. The result of this is that very concentrated urine is produced. Cortex The cortex is the outer part of the kidney. This is where blood is filtered. We call this process "ultra-filtration" or "high pressure filtration" because it only works if the blood entering the kidney in the renal artery is at high pressure. Billions of glomeruli are found in the cortex. A glomerulus is a tiny ball of capillaries. Each glomerulus is surrounded by a "Bowman's Capsule". Glomeruli leak. Things like red blood cells, white blood cells, platelets and fibrinogen stay in the blood vessels. Most of the plasma leaks out into the Bowman's capsules. This is about 160 litres of liquid every 24 hours. Most of this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and put back into the blood. Glomerulus and Bowman's Capsule This is where ultra-filtration takes place. Blood from the renal artery is forced into the glomerulus under high pressure. Most of the liquid is forced out of the glomerulus into the Bowman's capsule which surrounds it. This does not work properly in people who have very low blood pressure.

Proximal Convoluted Tubules Don't worry about remembering the name for your GCSE biology. Jolly good though if you can. Proximal means "near to" and convoluted means "coiled up" so this is the coiled up tube near to the Bowman's capsule. This is the place where all that useful glucose is re-absorbed from the ultra-filtrate and put back into the blood. If the glucose was not absorbed it would end up in your urine. This happens in people who are suffering from diabetes. Loop of Henl This part of the nephron is where water is reabsorbed. Kidney cells in this region spend all their time pumping sodium ions. This makes the medulla very salty; you could say that this is a region of very low water concentration. If you remember the definition of osmosis, you will realise that water will pass from a region of high water concentration (the ultra-filtrate and urine) into a region of low water concentration (the medulla) through cell membranes which are semi-permeable. Distal Convoluted Tubules Distal means "distant" so it is at the other end of the nephron from the Bowman's capsule. This is where most of the salts in the ultra-filtrate are re-absorbed. Collecting Duct Collecting ducts run through the medulla and are surrounded by loops of Henl. The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and salts are removed from it. Although our kidneys make about 160 litres of urine every 24 hours, we only produce about litre of urine. It is called a collecting duct because it collects the liquid produced by lots of nephrons.

Pathophysiology

Secondary Hypertension Arteriosclerotic lesions of the afferent and efferent arterioles Falling glomerular filtration rate Decrease capability of the kidneys to excrete waste products

Due to hypertension, there is lesion to the afferent and efferent arterioles decreasing the effectiveness of the filtration of blood in the glomerular that leads to the decrease capability of the kidney to properly excrete waste products.

Definition of Diagnosis 1. Chronic Kidney Disease (CKD) Secondary Hypertension DIAGNOSIS RATIONALE

1. CKD is a progressive, irreversible loss of kidney function that develops over days to years. Aggressive management of Chronic Kidney hypertension and diabetes mellitus and avoidance of nephrotoxic Disease (CKD) agents may slow progression of CKD; however loss of glomerular filtration is irreversible and can lead to end-stage renal disease (ESRD). 2. CKD is a term that describes kidney damage or a decrease in glomerular filtration rate for 3 or more months. Untreated CKD can result in end-stage renal disease (ESRD) and necessitate renal replacement therapy. 3. Chronic renal failure represents progressive and irreversible destruction of kidney structures. It results in loss of renal cells with progressive deterioration of glomerular filtration, tubular reabsorptive capacity, and endocrine functions of the kidney. 4. Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal function over a period of months or years. 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. 1. It is a persistently high blood pressure. In adults, this means a systolic pressure that is equal to or greater than 140 mmHg & a diastolic pressure that is equal to or greater than 90 mmHg. 2. Persistent elevation of the systolic blood pressure (SBP) at a level of 140 mmHg or higher & diastolip blood pressure (DBP) at a level of 90 mmHg or above. 3. A persistently high blood pressure. It is known as silent killer bcause it can cause considerable damage to the blood vessels, heart, brain, and kidneys before it causes pain or other noticeable symptoms. This damages the kidney arterioles, causing them to thicken, which narrow the lumen; because the blood supply to the kidney is thereby reduced, the kidney secrete more renin, which elevates the blood pressure even more.

Hypertension

Diagnostic Procedures Hematology Result 7.6 124 0.40 0.82 0.13 0.05 0.00 0.00 0.00 188 Received : Jan. 3, 2012 Normal 4.5-11.0x10^9 /L 123-153 g/L 0.36-0.45 0.18-0.70 0.10-0.48 0-0.04 0-0.03 0-0.01 0-0.03 150-400 10^9/L

WBC HGB HCT Differential count Neutrophils Lymphocytes Monocytes Eosinophils Basophils Bands Platelet count January 3, 2012 Test Result Unit Normal values

Results

Unit

Normal values

Analysis and Interpretation

Creatinine

371.28 high

mmol/L

53.0

1.30

4.2

mg/dl

0.60

1.30

Sodium

138.3 normal

mmol/L mmol/L

136 3.5

145 5.50

Result was above normal thus showing inability of the kidney to excrete nitrogenous waste. Result was normal Result was slightly below normal thus may indicate fluid and electrolyte imbalance.

Potassium 3.48 low

ULTRASOUND OF THE WHOLE ABDOMEN (July 28,2011) IMPRESSION: Contracted gallbladder precludes adequate evaluation (Post-prandial) Repeat GB ultrasound after 3 days of low fat meals suggested, if clinically indicated. Small sized native kidneys with signs of chronic parenchymal disease. Almost empty urinary bladder precludes evaluation. Atrophic anteverted uterus with tiny anterior myoma. Ultrasonically unremarkable liver, biliary tree, pancreas, spleen, aorta and renal graft. Negative for pelvic- fluid

Management Therapuetics Date 1/2/12 Order Rationale Venoclysis of 0.3%NaCl to run at 0.3%NACL is a solution of common KVO rate. salt in distilled water, of strength of 0.3%. It is an isotonic solution. It is less irritating for the body cells. It is used to patients with salt and water deprivation. KVO rate is ordered for prophylactic access. I & O q shift and VS q 4 This measures how much fluids are taken and how much has been excreted. This also indicates any problem in the kidneys. Vital signs are done every 4 hours to monitor the clients well being such as temperature which is indicative of hyperthermia.

1/2/12

1/2/12

Low purine, Low salt and Low fat Diet for CKD patients must be diet accurately weighed or gauged. too much protein and fats may overwork the liver and kidneys. Moderate high back rest Promotes thoracic expansion and facilities breathing. Hemodialysis (also haemodialysis) is a method for extracorporal removing waste products such as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure.

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1/3/12

Hemodialysis

Drug Study Calcium Carbonate Mode of Action: Essential for nervous, muscular, and skeletal systems. Maintain cell membrane and capillary permeability. Act as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal and smooth muscles. It is essential for bone formation and blood coagulation. It is also used a replacement of calcium in deficiency states. It controls of hyperphosphatemia in end-stage renal disease without promoting aluminum absorption. Interactions: Hypercalcemia increases the risk of digoxin toxicity. Chronic use with antacids in renal insufficiency may lead to milk-alkali syndrome. Ingestion by mouth may decrease the absorption of orally administered tetracyclines, fluoroquinolones, phenytoin, and iron salts. Excessive amounts may decrease the effects of calcium channel blockers, atenolol. Concurrent use with diuretics may result in hypercalcemia. Side Effects: CNS: syncope, tingling CV: cardiac arrest, arrythmias, bradycardia GI: constipation, nausea, vomting GU: calculi, hypercalciuruia Local: phlebitis (IV only)

Nursing Responsibilities: 1. Monitor VS especially BP and PR. 2. Obtain ECG result. 3. Asses for heartburn, indigestion, abdominal pain. 4. Monitor serum calcium before treatment. 5. Assess for nausea and vomiting, anorexia, thirst, severe constipation.

Sodium Bicarbonate Baking Soda, Bell-Ans, Citrocarbonate, Neut, Soda Mint (650 mg 1 tab tid) Classification: Anti-ulcer agent and alkalinizing agent Desired Dosage: Alkalinization of urine: (PO) 48 mEq or 4 g initially. Then 1-2 g q4 hr or 1 tsp of powder q4 hr as needed. Metabolic acidosis: >4.8 g/day as needed. Mode of Action: Acts as an alkalinizing agent by releasing bicarbonate ions. It is used to alkalinize urine and promote excretion of certain drugs in overdosage situations. Interactions: Increase toxicity of amphetamins, ephedrine, pseudoephedrine, flecainide, quinidine and quinine. It decreases effects of lithium, chlorpropamide and salicylates due to increased clearance. It may affect the absorption of certain drugs due to raised intra-gastric pH. Side Effects: Metabolic alkalosis; mood changes, tiredness, shortness of breath, muscle weakness, irregular heartbeat; muscle hypertonicity, twitching, tetany; hypernatraemia, hyperosmolality, hypocalcaemia, hypokalaemia; stomach cramps, flatulence. Nursing Responsibilities: 1. Assess for signs of acidosis (disorientation, headache, weakness, dyspnea, hyperventilation), alkalosis (confusion, irritability, paresthesia, tetany, altered breathing pattern), hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed skin, mental irritability), or hypokalemia (weakness, fatigue, arrhythmias, polyuria, polydypsia) 2. Assess fluid balance (intake and output, daily weight, edema, lung sounds) 3. Take med with full glass of water. 4. Monitor serum electrolyte concentrations, serum osmolarity, acid-base balance, and renal function prior to and periodically through out the therapy.

Epoetin B Recormon (5000 u SC) Classification: Hematopoeitic Agent Desired Dosage: 50-100 u/kg 3x weekly initially, then adjust dose base on Hct. Anemia w/ CRF: Correction phase SC inj Initially, 3 x 20 iu/kg/wk, may be increased every 4 wk by 3 x 20 iu/kg/wk if the increase of packed cell vol (PCV) is inadequate (< 0.5% per wk). Wkly dose can be divided into daily doses or administered as a single dose. Max: 720 iu/kg/wk. IV inj Initially, 3 x 40 iu/kg/wk. Dose may be increased after 4 wk to 3 x 80 iu/kg/wk. If further increments are needed, increase at 20 iu/kg 3 times wkly at mthly intervals. Max: 720 iu/kg/wk. Maintenance phase In SC inj, to maintain a PCV of 30-35%, initially reduce to of the previously administered amount. Subsequently, adjust dose at 1-2 wk intervals individually for the patient. Patient stable on a once-wkly dosing regimen may be switched to once every 2 wk administration. Prevention of anaemia of prematurity SC inj 3 x 250 iu/kg/wk for 6 wk. Increasing the amount of autologous blood SC or IV inj Twice wkly over 4 wk. Max IV Dose: 1,600 iu/kg/wk. Max SC Dose: 1,200 iu/kg/wk. Symptomatic anaemia in cancer SC inj 1 inj/wk or 3-7 divided doses/wk. Recommended Dose: Initially, 30,000 iu/wk (approx 450 iu/kg body wt/wk based on ave wt). Treatment is indicated if haemoglobin value is 11 g/dL (6.83 mmol/L), should not exceed 13 g/dL (8.07 mmol/L). After 4 wk therapy, if haemoglobin value increased by at least 1 g/dL (0.62 mmol/L), continue therapy; if not, double the wkly dose. After 8 wk, if value has not increased by at least 1 g/dL, discontinue therapy. After the end of chemotherapy, continue therapy up to 4 wk. Max: 60,000 iu/wk. When therapeutic objective has been achieved, reduce dose by 25-50% to maintain haemoglobin at that level, may reduce further to ensure haemoglobin level does not exceed 13 g/dL. If >2 g/dL (1.3 mmol/L) haemoglobin rise in 4 wk, reduce dose by 25-50%. Mode of Action: Epoetin beta is identical in its amino acid and carbohydrate composition to erythropoietin that has been isolated from the urine of anemic patients. Erythropoietin is a glycoprotein that stimulates the formation of erythrocytes from precursors of the stem cell compartment. It acts as a mitosis-stimulating factor and differentiation hormone.

After administration of epoetin beta, the number of erythrocytes, the Hb values and reticulocyte counts increase as well as the 59Fe-incorporation rate. An increased 3Hthymidine incorporation in the erythroid-nucleated spleen cells has been found in vitro (mouse spleen cell culture) after incubation with epoetin beta. Interaction: The clinical results obtained so far do not indicate any interaction of Recormon with other substances. Incompatibilities: To avoid incompatibility or loss of activity, do not mix with other drugs or infusion solutions. Side Effects: CNS: Seizures, headache CV: Hypertension, thrombotic events such as MI or stroke Derm: Transient rashes

Nursing Responsibilities: 1. Monitor blood pressure before and after therapy. Additional antihypertensive drug maybe required during initiation of therapy. 2. Monitor Hct and other hematopoietic parameters (CBC with differential and platelet count) 3. Monitor renal function studies and electrolytes closely. Increase in BUN, creatinine, uric acid, phosphorus, and potassium may occur. 4. Do not shake vial because inactivation of medication may occur. 5. Discard vial immediately after withdrawing dose from single-use 1-ml vial. Refrigerate multi-dose 2-ml vial; stable for 21 days after initial entry. 6. Stress importance of compliance with dietary restrictions, medications, and dialysis. Foods high in iron and low in potassium include liver, pork, veal, beef, mustard and turnip greens, etc

Tranmadol Hydrocholoride Generic Name: Tramadol Hydrocholoride Brand Name: Ultram Classification: Analgesic Indication: is indicated for the management of moderate to moderately severe pain (Flank Pain) in adults. Action: A centrally synthetic analgesic compound not chemically related to opioids. Adverse Reaction: Central Nervous System: Anxiety, Confusion, Coordination disturbance, Nervousness, Sleep disorder. Gastrointestinal: Abdominal pain, Anorexia, Flatulence. Skin: Rash. Special Senses: Visual disturbance. Urogenital: Menopausal symptoms, Urinary frequency, Urinary retention. Nursing responsibilities: 1. Reassess patients level of pain at least 30 minutes after administration. 2. Monitor CV and respiratory status. With hold dose and notify the physician if RR decrease or rate is below 12 breaths/min. 3. Monitor bowel and bladder function. 4. For better analgesic effect, give drug before onset of intense pain.

Catapres Generic Name: Catapres Brand Name: Clonidine Classification: Antihypertensive Drug Indication: are indicated in the treatment of hypertension. Action: Thought to stimulate alpha2 receptors, decreasing sympathetic outflow to the heart, kidneys and peripheral vasculature, and lowering vascular resistanceBP, and HR. Adverse Reaction: Cardiovascular: Bradycardia, Orthostatic hypotension Central Nervous System: Agitation, anxiety, delirium, delusional perception, hallucinations (including visual and auditory), insomnia, mental depression Dermatological: Alopecia, edema, pruritus, rash. Gastrointestinal: Abdominal pain, anorexia, constipation, hepatitis, malaise, nausea, vomiting. Genitourinary: Decreased sexual activity, difficulty in micturition, erectile dysfunction, loss of libido, nocturia, and urinary retention. Metabolic: Gynecomastia, weight gain. Musculoskeletal: Leg cramps and muscle or joint pain. Ophthalmological: blurred vision, burning of the eyes, decreased lacrimation, and dryness of eyes. Nursing responsibilities: 1. Drug may be given to lower blood pressure and sure rapidly in some hypertensive emergencies. 2. Monitor BP and PR frequently. Dosage is usually adjust to patients BP and tolerance. 3. Observe patients for tolerance to drugs therapeutics effects, which may require increased in dosage.

DILTIAZEM Generic Name: Diltiazem HCL Brand Name: Cardizem Classification: calcium channel blockers Indication: is used to treat hypertension (high blood pressure) Action: A calcium channel blocker that inhibits calcium ion influx across cardiac and smooth muscles cells, decreasing myocardial contractility and oxygen demand. Adverse Reaction: CNS: Headache, Dizziness CV: Edema, Arrhythmias, Bradycardia, Hypotension GI: Nausea, Contipation, Abdominal distention. Skin: Rashes Nursing responsibilities: 1. Monitor BP and HR when starting therapy and during dosage adjustments. 2. Maximum antihypertensive effect may not be seen in 14 days. 3. If systolic BP is below 90mmHg or HR is below 60 beats/minute, with hold dose and notify physician.

MICARDIS Generic Name: Telmisartan Brand Name: Micardis Classification: Antihypertensive Drug Indication: is used to treat hypertension (high blood pressure) Action: Blocks vasoconstricting and aldosterone secreting effect of angiotensin II by selectively blocking the binding of angiotensin II to the angiotensin I receptor in many tissues, such as vascular smooth muscle and the adrenal gland. Adverse Reaction: CNS: Dizziness, Headache, Nervousness CV: Palpitations, orthostatic hypotension, tachycardia. GI: Nausea GU: impotence, priapism Musculoskeletal: back pain, muscle pain. Resp: Dyspnea Nursing responsibilities: 1. Monitor BP frequently. 2. Tell Pt. Not to stop drug suddenly, but to notify prescriber if adverse reactions occur. 3. Tell Pt. That light headedness can occur, especially during the first few days of therapy. Advise him to rise slowly to minimize the effect.

Ketosteril Generic Name: Essential Amino Acid Brand Name: Ketosteril Classification: Ketoanalogs; Essential amino acids Indication: Protein energy malnutrition, Prevention and treatment of conditions caused by modified or insufficient protein metabolism in chronic renal failure Action: Normalizes metabolic process, promotes recycling product exchange. Reduces ion concentration of potassium, magnesium and phosphate. Adverse Reaction: 1. Hypercalcemia may develop 2. Allergy and hypersensitivity to any content of this drug Nursing responsibilities: 1. 2. 3. 4. 5. Evaluate for any contraindications Take drug as prescribed Warn the patient about possible side effects and how to recognize them Give with food if GI upset occurs Frequently assess for hypercalcemia

Discharge Planning M- Medication Instruct to comply strictly with prescribed home medications Erythropoietin 4,000 units SC twice a week as prescribed CaCO I tab TID PO as prescribed NaHCO3 I tab TID PO as prescribed Antihypertensive drugs as prescribed E- Exercise Encourage mild and non strenuous exercise T- Treatment Advice patient to avoid stress related factors H Health teachings Encourage deep breathing exercise Adequate bed rest O- Out patient Instruct to be present on follow up check ups Emphasize the need to be present in medical procedures schedule such as hemodialysis D- Diet Maintain on low salt low fat diet Limit fluid intake

Conclusion This case study attempted to provide information about the illness regarding the patients medical condition. This presentation targets the mind of readers to provide related information, familiarize and educate on the prevention, detention, treatment and evaluation of patients with Chronic Kidney Disease. It enhances the awareness of the medical team especially the nurses in providing critical and competent nursing care in handling the case. For the presenters, it was a great opportunity to be embodied with intellect and skills in providing nursing care for patients suffering from CKD. The critical care course and case presentation opened the mind of each presenters and participants in dealing with different nursing situations that requires further competent nursing care. May this presentation served its purpose of providing relevant information in enhancing our skills as professional critical care nurses.