case analysis fin

8/7/2019 CASE ANALYSIS FIN

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PREPARED BY:

DIANNE MAE E. MACARAIG

BSN 4D SHC

CASE ANALYSIS

CHRONIC KIDNEY

DISEASE


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Patient Data Profile

y Demographic DataName: Mr. X

Age: 58 y/o

Sex: Male

Civil Status: Married

Religion: Roman Catholic

y Admission Data

Date of Admission: January 7, 2011

Attending Physician: Dra. Tayao

Chief complaint: difficulty of breathingDiagnosis: Chronic Kidney Disease


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Chronic kidney

disease

DISEASE ENTITY


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y 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.

y occurs when one suffers from gradual and usually

permanent loss of kidney function over time. This

happens gradually, usually months to years. Chronic

kidney disease is divided into five stages of increasing

severity

y The term "renal" refers to the kidney, so another name

for kidney failure is "renal failure.

y Mild kidney disease is often called renal insufficiency.


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yWith loss of kidney function, there is anaccumulation of water; waste; and toxic substances,

in the body, that are normally excreted by the

kidney.

Loss of kidney function also causes other problemssuch as

y anemia,

y

high blood pressure,y acidosis (excessive acidity of body fluids),

y disorders of cholesterol and fatty acids, and

y bone disease.


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y Stage 5 chronic kidney disease is also referred to as

kidney failure, end-stage kidney disease, or end-

stage renal disease, wherein there is total or near-total loss of kidney function. There is dangerous

accumulation of water, waste, and toxic

substances, and most individuals in this stage of

kidney disease need dialysis or transplantation tostay alive.


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y Unlike chronic kidney disease, acute kidney failure

develops rapidly, over days or weeks.

y Acute kidney failure usually develops in response to a

disorder that directly affects the kidney, its blood

supply, or urine flow from it.

y

Acute kidney failure is often reversible, with completerecovery of kidney function.

y Some patients are left with residual damage and can

have a progressive decline in kidney function in the

future.y Others may develop irreversible kidney failure after

an acute injury and remain dialysis-dependent.


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Stage DescriptionGFR*

mL/min/1.73m2

1Slight kidney damage with normal

or increased filtrationMore than 90

2 Mild decrease in kidney function 60-89

3Moderate decrease in kidney

function30-59

4Severe decrease in kidney

function15-29

5 Kidney failure Less than 15 (or dialysis)


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Causes

1. Type 1 and type 2 diabetes mellitus cause a condition calleddiabetic nephropathy, which is the leading cause of kidney

disease in the United States.

2. High blood pressure (hypertension), if not controlled, can

damage the kidneys over time.3. Glomerulonephritis is the inflammation and damage of the

filtration system of the kidneys, which can cause kidney

failure. Postinfectious conditions and lupus are among the

many causes of glomerulonephritis.4. Polycystic kidney disease is an example of a hereditary

cause of chronic kidney disease wherein both kidneys have

multiple cysts.


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5. Use of analgesics such as acetaminophen (Tylenol) andibuprofen (Motrin, Advil) regularly over long durations of

time can cause analgesic nephropathy, another cause ofkidney disease. Certain other medications can also damagethe kidneys.

6. Clogging and hardening of the arteries (atherosclerosis)leading to the kidneys causes a condition called ischemic

nephropathy, which is another cause of progressive kidneydamage.

7. Obstruction of the flow of urine by stones, an enlargedprostate, strictures (narrowings), or cancers may alsocause kidney disease.

8. Other causes of chronic kidney disease include HIVinfection, sickle cell disease, heroin abuse, amyloidosis,kidney stones, chronic kidney infections, and certaincancers.


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Symptomsy Effects and symptoms of chronic kidney disease include;

1. need to urinate frequently, especially at night (nocturia);

2. swelling of the legs and puffiness around the eyes (fluidretention);

3. high blood pressure;

4. fatigue and weakness (from anemia or accumulation of wasteproducts in the body);

5. loss of appetite, nausea and vomiting;6. itching, easy bruising, and pale skin (from anemia);

7. shortness of breath from fluid accumulation in the lungs;


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8. headache, numbness in the feet or hands (peripheral

neuropathy), disturbed sleep, altered mental status(encephalopathy from the accumulation of waste

products or uremic poisons),

9. Chest pain due to pericarditis (inflammation around the

heart);

10. bleeding (due to poor blood clotting);

11. bone pain and fractures; and

12. decreased sexual interest and erectile dysfunction.


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Anatomy and

Physiology


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URINARY SYSTEM


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Normal Kidneys and Their Function

y The kidneys are a pair of bean-shaped organs that lie on

either side of the spine in the lower middle of the back.Each kidney weighs about pound and containsapproximately one million filtering units called nephrons.

y Each nephron is made of a glomerulus and a tubule.

y The glomerulus is a miniature filtering or sieving devicewhile the tubule is a tiny tube like structure attached tothe glomerulus.

y The kidneys are connected to the urinary bladder bytubes called ureters.

y Urine is stored in the urinary bladder until the bladder isemptied by urinating. The bladder is connected to theoutside of the body by another tube like structure calledthe urethra.


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The main function of the kidneys

1. is to remove waste products and excess water from the blood.The kidneys process about 200 liters of blood every day and

produce about two liters of urine.

2. The waste products are generated from normal metabolic

processes including the breakdown of active tissues, ingestedfoods, and other substances.

3. The kidneys allow consumption of a variety of foods, drugs,

vitamins and supplements, additives, and excess fluids

without worry that toxic by-products will build up to

harmful levels.

4. The kidney also plays a major role in regulating levels of

various minerals such as calcium, sodium, and potassium in

the blood.


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y As the first step in filtration, blood is delivered into the

glomeruli by microscopic leaky blood vessels called

capillaries. Here, blood is filtered of waste products and

fluid while red blood cells, proteins, and large molecules

are retained in the capillaries. In addition to wastes,

some useful substances are also filtered out. The filtrate

collects in a sac called Bowman's capsule.

y The tubules are the next step in the filtration process.

The tubules are lined with highly functional cells which

process the filtrate, reabsorbing water and chemicals

useful to the body while secreting some additional wasteproducts into the tubule.


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PATHOPHYSIOLOGY


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LABORATORY RESULT

January 7, 2011


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CHEST X-RAY

y FIBROTICDENSITIES ARE NOTED, INTHERIGHTUPPER LOBE

y HEARTIS NOTENLARGED

y AORTA ISTORTUOUS AND CALCIFIED

y ELEVATED RIGHTHENIDIAPHRAGM

y RIGHTHEMIDIAPHRAGMAND SULCUS ARE PRESERVESINTACTBONYTHORAX.

y IMPRESSION:

y FIBROTICPTB, RIGHT.y ATHEROMATOUS AORTA

y ELEVATED RIGHTHEMIDIAPHRAGM, ETIOLOGY?


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COMPLETE BLOOD COUNT

TES

T RESUL

TN

ORMAL VALUES

IN

TE

RP

RE

TA

TION

CREATININE 70.7 62 - 124 umol/L Within normal range

SODIUM 135.4 134 148 mmol/L Within normal range

POTASSIUM 3.33 3.5- 5.3 mmol/L (hypokalemia)

commonly result from

aldosteronism or cushing

syndrome, loss of body

fluids( as with long-termdiuretic therapy)


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January 8, 2011


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BLOOD CHEMISTRY

TEST RESULT NORMAL VALUES INTERPRETATION

HEMOGLOBIN 9.5 14.0 18 gm/dL indicates anemia, recent hemorrhage or fluid

retention, causing hemodilution

HEMATOCRIT 28 40 50 gm/dL indicates anemia, hemodilution or massive

blood loss

WBC 10,200 5,000- 10, 000/cumm

(leukocytosis) signals infection such asabscess, meningitis etc. it may also results from

leukemia and tissue necrosis from burns, MI or

gangrene

NEUTROPHILS 81 40- 60 indicates bacterial infection

LYMPHOCYTES 19 35 - 40 indicates defective lymphatic circulation;

decresed by severe debilitating illness like renal

failure and advanced TB


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DRU

G STU

DY


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Generic name/

dosage/BRAND

NAME

Mechanism of action Specific Indication Adverse

Reaction

Nursing responsibilities

/Route of administration

Paracetamol

500 mg 1 tab q4

PRN

Analgesic / antipyretic

- Decrease fever by

inhibiting the effect of

pyrogens on the

hypothalamic heat

regulating centers

- Control pain due to

headache

- To reduce fever in

bacterial or viral

infection

Urticaria

Rash

Jaundice

Drowsiness

Hemolytic

anemia

1. Monitor vital signs(

temp)

2. Take as directed with

food or milk to decrease

GIupset

3. Document presence of

pain/fever

4. Check urine for occult

blood.Kalium durule 1

tab TID

(Potassium

chloride)

Electrolyte and minerals

Potassium chloride is a

major cation of the

intracellular fluid. It plays an

active role in the conduction

of nerve impulses in theheart, brain and skeletal

musclecontraction of cardiac

skeletal and smooth muscle;

maintenance of normal renal

function, acid base balance,

carbohydrate metabolism,

gastric secretion

- For hypokalemia

- As prophylaxis

during treatment

with diuretics

Hyperkalemia

Rash

Vomiting

GIdiscomfort

ECGchanges

1. Administer oral drugs

after meals or with food

to decrease GIupset

2. Monitor serum

potassium level and ECG


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Generic name/

dosage/BRAND

NAME

Mechanism of action Specific Indication Adverse Reaction Nursing responsibilities /Route of

administration

Furosemide 60

mg IV q6 with BP

precaution

Loop diuretic

- Inhibits reabsorption

of sodium andchloride from the

proximal and distal

tubules as well as the

ascending loop of

henle. This results in

the excretion of

sodium, chloride andto a lesser degree,

potassium and

bicarbonate loss

- Treatment for

edema, as with

heart failure,hypertension

y Orthostatic

hypotension

y Urinarybladder

spasms

y Headache

y fatigue

1. Test if the patient is allergic to the

drug.

2. To prevent nocturia, give POandIMpreparations in the morning. Give

second dose in early afternoon.

3. Monitor weight, blood pressure, and

pulse rate routinely with long term

use and during rapid dieresis. Use

can lead to profound water and

electrolyte depletion.4. Monitor fluid intake and output and

electrolyte, BUN, and carbon

dioxide levels.

5. Watch for signs of hypokalemia,

such as muscle weakness and

cramps.

Ketosteril 60 mg

1 tab 2 tabs TID

ketoanalogues & essential

amino acids

- Normalizes metabolic

process, promotes

cycling product

exchange. Reduces

ion concentration of

potassim, magnesium

and phosphate.

- Prevention &

therapy of

damages due to

faulty/deficient

protein

metabolism in

chronicrenal

insufficiency.

y Hypercalce

mia..

1. Monitor regularly the serum calcium

level.

2. Ensure the sufficient supply with

calories


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NURSING CARE

PLAN


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SUBJECTIVE

y Namamanas ako at ang hina ng katawan ko (I have edema and

I feel very weak) as verbalized by the patient

OBJECTIVE:

y Venous distension

y weight gainy Adventitious breath sound like wheezing

y Patient reports of Fatigue, weakness, and malaise

y Decreased hgb and hct

y V/S taken as follows

T: 35CP: 50

R: 13

BP: 130/90

y Abdominal circumference= 37 inches

y Weight= 50 kls.

1. Fluid Volume excess r/t Compromised

regulatory mechanism (renal failure)


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PLANNING and EVALUATION

After 8 hours of Nursing intervention, the patient

will

display Appropriate urinary output with specificgravity/laboratory studies near normal;

stable weight, vital signs within patients

normal range; and

absence of edema


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INTERVENTION and RATIONALE

1.Record accurate intake and output (I&O).

y Accurate I&O is necessary fordetermining renal function and fluid

replacement needs and reducing risk of fluid overload

2.Weigh daily at same time ofday, on same scale, with same

equipment and Clothing/ measure Abdominal girth

y Daily body weight is best monitor of fluid Status

3.Assess skin, face, dependent areas for Edema

y Edema occurs primarily in dependent tissues of the body, e.g., hands,

feet, lumbosacral area. Patient can gain up to 10 lb (4.5 kg) of fluid

before pitting edema is detected

4. Plan oral fluid replacement with patient, within multiple

restrictions

y Helps avoid periods without fluids, minimizes boredom of limited

choices, and reduces sense ofdeprivation and thirst


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5.Administer/restrict fluids as indicated.

y Fluid management is usually calculated to replace

output from all sources plus estimated insensible losses6. Administer medication as IndicatedDiuretics, e.g.,

furosemide (Lasix), mannitol (Osmitrol)

yGiven early in oliguric phase of Renal Failure in an

effort to convert to nonoliguric phase, flush the tubularlumen ofdebris, reduce hyperkalemia, and promote

adequate urine volume.

7..Antihypertensives, e.g., clonidine (Catapres)

yMay be given to treat hypertension by counteracting

effects ofdecreased renal blood flow and/or circulating

volume overload


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2. Imbalanced nutrition less than body requirement

related to inability to ingest food; inability to absorb

nutrients

SUBJECTIVE:

Ang sakit ng tiyan ko as verbalized by the patient

OBJECTIVE:

y Weakness of muscle required for swallowing

y

Poorly nourished body appearancey Incomplete set of teeth

y Abnormal laboratory studies ( electrolyte imbalance

y Potassium is decrease (3.33 mmol/L)


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After 3 days of Nursing intervention, the patient will be

able to:

y Demonstrate progressive weight gain toward goal

y Display normalization of the laboratory valuesy Verbalize understanding of causative factors when known

and necessary interventions

y

Demonstrate behaviors, lifestyle changes to regainand/or maintain appropriate weight


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1. Determine clients ability to chew, swallow and tastefood. Evaluate teeth and gums for poor oral health

yAll factors that can affect ingestion and/or digestion of

nutrients

2.Ascertain understanding of individual nutritional needs

yTo determine informational needs of the client

3.Assess drug interactions, disease effects, allergies, use of

laxatives, diureticsyThis may be affect the appetite, food intake or

absorption


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4.Assess weight; measure the body fat and muscle mass via

triceps skin fold and mid arm muscle circumference orother anthropometric measurements

yTo establish baseline parameters

5. Promote adequate and timely fluid intake. Limit fluids 1

hour prior to meal

yTo monitor effectiveness of efforts

6.Weigh at regular intervals and document results

yTo monitor effectiveness of dietary plan


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3. Deficient knowledge r/t unfamiliarity

with information resources

SUBJECTIVE:

y Hindi ko maintindihan kung bakit ganito ang nararamdaman

ko at kung bakit ang lake ng tiyan ko as verbalized by thepatient

OBJECTIVE:

y Inappropriate or exaggerated behaviors


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After 8 hours of Nursing intervention, the patient will be able to:

y Identify interferences to learning and specific actions to deal with

them

y Verbalize understanding of condition, disease process andtreatment

y Identify relationship of signs and symptoms to the disease process

y Initiate necessary lifestyle changes and participate in treatment

regimen.


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1. Determine clients ability, readiness and barriers to learning

y Individual may not be physically, emotionally or mentally

capable at this time

2. Be alert to signs of avoidancey Client may need to suffer consequences of lack of knowledge

before he is ready to accept information

3. Provide positive reinforcement

y It can encourage continuation of efforts4. Discuss clients perception of need. Relate information to

clients personal desires, needs, values and beliefs

y So that client feels competent and respected


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5. Begin with information the client already knows and move to

what the clients does not know, progressing form simple to

complexy It Can arouse interest/ limit sense of being overwhelmed

6. Deal with clients anxiety or other strong emotions

y Anxiety will interfere clients ability to learn

7. Provide active role for client in learning process

y To promote sense of control over situation and means for

determining the client is assimilating and using new

information.

8. Provide access information for contact person

y To answer questions and validate information post discharge


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DISCHARGE PLAN


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M The patient may still continue taking medications if some

untoward s/sx occurs like diarrhea, fever, and vomiting. Yet, itmust be in accordance to the order of the physician.

Medications should not be taken without any precautions and

advice from the doctor.

y Instruct the patient and SO, the importance of compliance to

medicines to achieve appropriate therapeutic effects.

y Home Medications:

Ketosteril 600 mg tab 2 tabs 3 x 1 dayFurosemide 60 mg tab 1 tab 2 x/ day x 7 days


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E The environment must be free from possible injury. The

floor should not be slippery. If possible trees and flowers

around can also be present to provide good and fresh air from

the patient.

y Encourage SO to provide peaceful environment conducive for

fast recovery and healthy living.y Advise SO to reduce environment destruction as much as

possible so that the client could have an undisturbed sleep.

T Encourage the SO to compliance on further treatment for

the proper maintenance and gain of optimal health.

y If for rehabilitation, it should be attended


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H Regular check-up in health centers helps maintain

patients health.y Limit fluid intake to 1 L/day

y Adequate rest and sleep

y Keep back dry at all times

y Importance of adherence to treatment and medical

management

y Importance of rising slowly to sitting or standing position to

minimize orthostatic hypotension


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O Inform SO regarding future check-ups and treatment and

the importance of compliance to the scheduled procedures to

maintain and monitor the clients health.y Any patient check-up must be attended to know if the

condition is improving.

D Balanced diet

y Increase protein (fish, egg, meat)

y Decrease fats

y Avoid salty and fatty foods such as pork, beefy Fruits such as banana and apple


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Diagnostic testU

rine Testsy Urinalysis

y Twenty-four hour urine tests

y Glomerular filtration rate (GFR)

Blood Tests

y Creatinine and urea (BUN) in the blood

y E

stimated GFR (eGFR)y Electrolyte levels and acid-base balance

y Blood cell counts


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Other tests

y Biopsy

y Ultrasound


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When to Seek Medical Care

Several signs and symptoms may suggest complications ofchronic kidney disease. Call your health care practitionerif you notice any of the following symptoms:

y Change in energy level or strength

y Increased water retention (puffiness or swelling) in thelegs, around the eyes, or in other parts of the body

y Shortness of breath or change from normal breathing

y Nausea or vomiting

y Lightheadedness

y Severe bone or joint pain

y Easy bruising

y Itching


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The following signs and symptoms represent the

possibility of a severe complication of chronic kidney

disease and warrant a visit to the nearest hospital

emergency department.

y Change in level of

consciousness - extreme

sleepiness or difficult toawaken

y fainting

y Chest pain

y Difficulty breathingy Severe nausea and vomiting

y Severe bleeding (from any

source)

y Severe weakness


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Treatment


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Phosphorus restriction: Decreasing phosphorus intake is

recommended to protect bones. Eggs, beans, cola drinks, and

dairy products are examples of foods high in phosphorus.

Other important measures that you can take include:

1. carefully follow prescribed regimens to control

your blood pressure and/or diabetes;

2. stop smoking; and

3. lose excess weight.


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y In chronic kidney disease, several medications can be toxic tothe kidneys and may need to be avoided or given in adjusteddoses. Among over-the-counter medications, the following

need to be avoided or used with caution: Certain analgesics: Aspirin; nonsteroidal antiinflammatorydrugs (NSAIDs, such as ibuprofen [Motrin, for example])

Fleets or phosphosoda enemas because of their high contentof phosphorus

Laxatives and antacids containing magnesium and aluminumsuch as magnesium hydroxide (Milk of Magnesia) andfamotidine (Mylanta)

Ulcer medication H2-receptor antagonists: cimetidine(Tagamet), ranitidine (Zantac), (decreased dosage withkidney disease)

Decongestants such as pseudoephedrine (Sudafed) especiallyif you have high blood pressure

Alka Seltzer, since this contains large amounts of salt

Herbal medications


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Medical Treatment

y

There is no cure for chronic kidney disease.The four goals of therapy are to:

1. slow the progression of disease;

2. treat underlying causes and contributing factors;

3. treat complications of disease; and

4. replace lost kidney function.


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Strategies for slowing progression and treatingconditions underlying chronic kidney disease include

the following:

y Diet

y Control of high blood pressure

y Control of blood glucose


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The complications of chronic kidney disease

may require medical treatment.

y Fluid retention can be treated with any of a number of diureticmedications, which remove excess water from the body. However,these drugs are not suitable for all patients.

y

Anemia can be treated with erythropoiesis stimulating agents suchas erythropoietin or darbepoetin (Aranesp, Aranesp Albumin Free,Aranesp SureClick).

y Bone disease develops in kidney disease due to an inability toexcrete phosphorus and a failure to form activated Vitamin D.

y Acidosis may develop with kidney disease. The acidosis may causebreakdown of proteins, inflammation, and bone disease. If theacidosis is significant, your doctor may use drugs such as sodium

bicarbonate (baking soda) to correct the problem.


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Medical and Surgical treatment

y Renal Replacement Therapies

y Dialysis

y Hemodialysis

y

Peritoneal dialysisy Kidney Transplantation


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Prevention

1. Kidney disease is usually advanced by the time symptoms appear. Ifyou are at high risk of developing chronic kidney disease, see your

health care practitioner as recommended for screening tests.

2. If you have a chronic condition such as diabetes, high blood

pressure, or high cholesterol, follow the treatmentrecommendations of your health care practitioner. See your

healthcare practitioner regularly for monitoring. Aggressive

treatment of these diseases is essential.

3. Avoid exposure to drugs especially NSAIDs (nonsteroidal antiinflammatory drugs), chemicals, and other toxic substances as

much as possible.


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Prognosis

There is no cure for chronic kidney disease. The natural course of

the disease is to progress until dialysis or transplant is required.

Patients with chronic kidney disease are at a much higher risk thanthe general population to develop strokes and heart attacks.

People undergoing dialysis have an overall five year survival rate of

32%. The elderly and those with diabetes have worse outcomes.

Recipients of a kidney transplant from a living related donor have atwo year survival rate greater than 90%.

Recipients of a kidney from a donor who has died have a two year

survival rate of88%.


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