case pres .med ward

8/8/2019 Case Pres .Med Ward

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I.Acknowledgement

This case presentation would not be possible without the strenght,

wisdom and guidance given to us by Almighty God in which help us the

fulfillment of this study.

To our patient,whom we greatly avknowledge her cooperation and

willingness in every nursing intervention we render and every health

teaching we said.

We would like to extend our deepest gratitude to our clinical instructor

Ms. Sandra Loberiano for granting us the opportunity in conducting a casepresentation.Through this we further enhance our knowledge and able to

practice the skills we learned in rendering quality nursing care.We thank

her patience and advices to keep us strong and focus to our case

presentation and in every nursing activity we done to our patient.


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II.Introduction

Chronic Kidney Disease (CKD,also called chronic renal failure or chronic renalinsufficiency) is defined as a structural or functional kidney abnormality that persist for atleast three months or a chronic and significant decrease in kidney function.

Some people with CKD have normal kidney function ( the kidneys are able tofilter and excrete easte products in the urine) and do not have a reduction in kidneyfunction over time.In other people cKD causes a reduction in the level of kidneyfunction, which declines further over time.A number of conditions can cause CKD anddetermining the cause can help determine the optimal therapy to slow the damage ofCKD.However some patients with CKD will eventually require dialysis or kidneytransplantation.

Renal insuffiency is a common feature of chronic TIN and its diagnosis must be

considered in any patient who exhibits renal insufficiency.In most cases howeverchronic TIN is insidious in onset, renal insuffiency is slow to develop and earliestmanifestation of the disease are those of tubular dysfunction.As such,it is important tomaintain a high index of suspicion of this entity whenever any evidence of tubulardysfunction is detected clinically.At this early stage removal of a toxic cause of injury orcorrection of the underlying systemic or renal disease can result in preservation ofresidual renal function.Of special relevance in patients who exhibit renal insufficiencycaused by primary TIN is the absence or modest degree of the two principal hallmarksof glomerular and vascular diseases of the kidney,salt retention manifested by edemaand hypertention anvd proteinuria which usually is modest and less than 1 to 2 g/d in

TIN.These clinical considerations notwithstanding a definite diagnosis of TIN can beestablished only by morphology of kidney tissue.

People with chronic kidney disease suffer from accelerated atherosclerosis andare more likely to develop cardiovascular disease than general population.Patientsafflicted with chronic kidney disease and cardiovascular disease tend to havesignificantly worse prognoses than those suffering only from the latter.In many CKDpatients previous renal disease or other underlying diseases are already known.a smallnumber presents with CKD of unknown cause.In these patients a cause is occationallyidentified retrospectively.


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IIII.Objective of the study

General Objective:

This study aims to be more knowledgeable about our patients condition and to

render quality nursing care in response to the specific disease.The primary goal of this study is to help us become competent in the basic

assessment and management of significant signs and symptoms in regards to chronickidney failure.

Specific Objectives:

y To distinguish chronic kidney disease in different stages.y To properly identified chronic kidney disease for proper assessment and

management.y To familiarize chronic kidney disease and render appropriate relief to this

kind of disease.


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IV.BIOGRAPHICAL DATA

Name: Patient X

Address: 152 Cadena de Amor St. Tondo Manila

Gender: Male

Birthday: June 4,1986

Religion: roman catholic

Nationality : Filipino

Attending Physician: Dra.Anceta/ Dr.Felipe

Date of Admission: February 8,2010. 5:00 pm

Admitting Diagnosis: Pleural effusion left. Chronic Kidney Failure

V.MEDICAL HISTORY

This is a case of 23 years old Filipino male was born on June 04, 1986 who

resides at Cadena de Amor St. Tondo Manila and who is a Roman Catholic. Admitted

on February 08, 2010 at 5:00 pm with chief complain of difficulty of breathing (DOB)

Vital signs taken as follows: BP: 140/110 mmHg, HR: 104 bpm, RR: 33bpm, T:37.7C.

His admitting diagnosis was pleural effusion left chronic kidney disease (CKD). He has

no previous hospitalization and no surgical operation; he has no known allergy to any

foods and medications. He has a family history of hypertension, heart disease, and

asthma. Last 2008 he had a chief complain of pain on his nape due to hypertension and

diagnosed of glumerulonephritis and he underwent to a hemodialysis regularly twice a

week before. He had no difficulty in urination or dysuria but sometimes he experienced

constipation. He doesnt smokes and drinks any alcoholic beverages.

Patients physical examination in hair, nail and head is normal; face is

symmetrical and no involuntary muscle movement. Eyes are in yellowish color noted

and ears, neck and tongue of patient is in normal. Chest and lungs moves symmetrically

with irregular breathing patterns. Abdomen and back area is in normal rhythm. Skin is


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normal in color and no jaundice noted and no evident of lesions in upper extremeties.

Patients lower extremeties have no presence of edema, masses, or varicous veins

noted.

VI.HISTORY OF PRESENT ILLNESS

The patient start complaining of Hypertension last 2008 with pain on the

back.Last week the patient is apparently well until last week he had difficulty in

breathing.

VII.PAST MEDICAL HISTORY

As Patient X was interviewed, the group had known that he has no known

allergies to food or medicine. He is negative for diabetes mellitus and is also negative to

pulmonary tuberculosis. When he gets sick, he usually gets well or rests at home. He

has not yet experienced being hospitalized before even with other illnessess. Patient X

has not been subjected to any surgical operations.

VIII.Family History

On patients mother side the most problem that they posess is being

hypertensive.Some members of the family also have an asthma.Cardiac problems is

most pronounced on his mothers side also.

IX.Personal and Social History

Patient doesnt smoke or drink alcoholic beverages.The main problem that he

exhibit is that he is fond of eating fatty and salty foods because he can resist the taste

of it.According to the mother of the patient he drinks ice tea and coffee more than the

usual intake with an average of 5 glasses a day.


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X.Assessment

A. REVIEW OF SYSTEM

Baseline Measurement/ Vital Signs

Blood Pressure: 140/110 mmHg

Pulse Rate: 104 bpm

Respiratory Rate:34 bpm

Temperature: 37.7C

y Head

Headache (-)

Head injury(-)

Seizures(-)

Fainting(-)

y Eyes

Blurred Vision(-)

Diplopia(-)

Glaucoma(-)

Cataract(-)

y Ears

Inspection(-)

Discharge: no discharge

Earache(-)

Tinnitus(-)

Vertigo(-)

y Nose

Epistaxis(-)


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Sinus Pain(-)

Allergy(-)

Post Nasal Discharge(-)

y Respiratory System

Difficulty of Breathing()

Asthma(-)

Shortness of Breathing(-)

Pain()

Tuberculosis(-)

y Cardiovascular System

History of Heart Murmurs(-)

Rheumatoid Fever(-)

Kawasaki Disease(-)

Hypertension()

Palpitation(-)

Anemia(-)

y Gastrointestinal system

Constipation()

Change in Bowel habits(-)

Rectal Pruritus(-)

Hemorrhoids(-)

Hepatitis(-)

Appendicitis(-)

y Genitourinary System

Urinary Tract infection(-)


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Hematuria(-)

Sexually Transmitted Disease(-)

Pelvic Inflammatory(-)

Hepatitis(-)

HIV(-)

Dysuria(-)

y Extremities

Varicose veins(-)

Pain or Stiffness of joint(-)

Any fracture or dislocations(-)

Edema(-)

Cyanosis(-)

Pallor(-)


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B.PHYSICAL EXAMINATION

Body Part Tools Findings Interpretation

Hair Inspection and

Palpation

-thick, black and fine

hair

-evenly distributed

-covering the whole

scalp

NORMAL

Head Inspection and

Palpation

-Head is

proportionate to

body

-No tendernessnoted upon

palpation

NORMAL

Face Inspection -face is symmetrical

and no involuntary

muscle movement.

NORMAL

Eyebrows Inspection -black evenly

distributed

NORMAL

Eyes Inspection and

Palpation

-symmetrical, non-

protruding

-equal palpebral

fissure

-no discharge and

discoloration

-cornea clean and

transparent()Corneal reflux

-iris no noted any

visible material

-black in color

NORMAL


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PERRLA

-yellowish sclera -Abnormal

Ears Inspection and

Palpation

- Facial skin

and aligned

outer canthus

of the eye

- No discharge

- Texture:

Elastic

- Hearing:

responds tonormal voice

NORMAL

Nose Inspection and

palpation

- Symmetric

and straight

- No lesions

- Non-tender

sinuses

NORMAL

Mouth (Lips teethand gums)

Neck

Inspection

Inspection and

palpation

-uniform pink colorsoft moist

-Smooth texture

-Complete teeth

-no receding gums

-with dental caries

-the neck is straight

with no visible mass

-symmetrical

NORMAL

NORMAL

Chest and Lungs Inspection and

palpation

-breathing pattern is

irregular

ABNORMAL


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Heart Auscultation - HR of 104

- Normal

rhythm

NORMAL

Upper extremities,

abdomen and lower

extremities

Inspection -Symmetrical

-no lesions

Normal skin color

-no evident of lesion

-no masses

-no edema

-no presence of

varicosities

NORMAL


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XI.GORDONS LEVEL OF FUNCTIONING

Gordons Level of

Functioning

Pre-

Hospitalization

During

Hospitalization

Interpretation

Eating Pattern The patient eats3 major meals ina day and snacksbetween themajor meals. Itsamount and thefrequency ofsnacks willdepend upon herappetite.

Since the diseasehas beendiagnosed, heneeds to limit theamount of foodand the there isrestriction

Foods areessential for thefunction of thebody becausefood givesnutrients andprovide energyfor the dailyactivities. Eatingnutritious foods

like vegetables,meat and fruitsare important toinclude in the diet

Drinking Pattern The patient drinksan average of 5cup of coffee andice tea and 8-10glasses of waterin a day.

In the hospital,the patient drinkswater only

Human bodycompose of 60-75 % of waterand enoughintake of waterare important forthe fluid and

electrolytebalance.EliminationPattern

The patient iscapable of goingto the bathroomon his own, ableto urinate anddefecate withoutpain butsometimesconstipated.

Even though heis on the hospital,he is able tourinate anddefecate withoutpain, however heneeds someoneto go with him,because of his

contraption

An alteration canbe seen in thepatientseliminationpattern is thedefecation,wherein there issometimesconstipation

Bathing Pattern The patient wasable to performhygienemeasures

The patient wasnot able to batheinstead he justsponge her body

Performingpersonal hygieneis important forprevention offurthercomplication byreducing the


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microorganism onthe body.

Sleeping Pattern The patientsleeps on time forat least 8 hours a

day.

The patient canno longer sleep atabout 8 hours in

a day and wasnot comfortablewith his situation.

The patients hasdisturbedsleeping pattern

due to hercondition

Activity/ExercisePattern

The patients doesnot have a job,instead he justhelp his motheron the householdchores

There is arestriction on hismobility due thepain he felt.

An alteration canbe seen on thepatients activityand exercise dueto hiscontraptions andthe pain.

Self-perception/

Self-conceptpattern

The patient

perceived hisbody asphysically fit andhealthy becausehe didnt noticeany sin andsymptoms ofdisease.

The patient

realized after allthat he isexperiencingsuch kind ofdisease and hasa positiveperception thatafter all this hislife together withhis family willback to normal

way.

Due to disease

he can comeback to hisnormal living withhis family.

Role/relationshippattern

The patient isalso a bredwinner in a littleway. According tohim he needs tosurvive and livelonger for hisfamily andfriends.

The patient wasclose to hisfamily.

The relationshipof the patienttowards familynever changed.

Coping stress/

Tolerance pattern

Whenever the

patient feels painthrough her bodyshe prefers totake a rest on hisown and takesome medicinesto relieve thepain. Sometimes

Sometimes the

patient was ableto voice out to thedoctor andnurses inside thehospital thosepains that he feltwith his body.

The patient is

now capable oftelling thosepains he feltwhen somebodyis asking.


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when his family isnot around hefelt alone andsad.

Spiritual pattern The patient

attended churchbut not allSunday

The patient is not

capable to go tochurch but hedon not forget topray.

He still believes

and have faith toGod the patient isactive when itcomes tospiritual concern.

XII.ANATOMY AND PHYSIOLOGY: The Kidneys

y The kidneys are two bean-shaped organs located retroperitoneally at the level of

12th thoracic and third lumbar vertebra.

y The right kidney is lower than the left kidney due to the presence of the liver on

the other right side of the abdomen.

y The kidneys are divided into renal cortex medulla and pelvis. The medulla is

composed of pyramids.


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y The functional units of the kidneys are the nephrons. The nephrons is composed

glomerumerulus and the renal tubules

y The primary function of the nephron is for urine formation.

y Through the formation of urine, the kidneys remove waste products from the

body, regulate fluid volume, and maintain electrolyte concentration, blood

pressure and pH within the body.


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XIII.PATHOPHYSIOLOGY

yGLOMERULONEPHRITIS HYPERTENSION

REMAINING NEPHRONS UNDERGOCHANGES TO COMPENSATE FOR

DAMAGED NEPHRONS

DECREASE RENAL PERFUSIONDECREASE BLOOD FLOW

GLOMERULI AND TUBULES ARESCARRED ANS BRANCHES OF RA

THICKENS

INCREASE PERIPHERAL RESISTANCE/INCREASE PRESSURE IN THE BLOOD

VESSELS

INTOLERANC

E AND EXHAUSTION OFREMAINING NEPHRONS

IMPAIRED FUNCTION OF KIDNEY

UREMIA (CHRONIC RENAL FAILURE)

HYPERTROPHY OF NEPHRONS

HYPERTENSION

INCREASE OF BLOOD PRESSURE

MALFUNCTION OF RAAS PROTEINURIA

DECREASE PROTEIN IN BLOOD

PLEURAL EFFUSION


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XV. LABORATORY RESULT February 1, 2010

Name: Patient

Constituent Rationale Conventional SI unit

Result Normalvalue Result Normal value

ALT/ SGPT Studies are based

on release of

enzymes from

damage liver cells.

These are elevated

in liver damage.

10.9 u/l 10-50u/l 10.9u/l 10.9u/l

AST/ SGOT 9.5 u/l 0-38u/l 9.5u/l 0-38u/l

Creatinine It is the acurate test

for kidney diseases.

17.58mg/dl 0.5-1.2m/dl 1.544

mmol/L

44-

106mmol/L

Glucose ( FBS) To know the glucose

level in the blood

93.5mg/dl 74-

106mg/dl

5.1mmol/L 4.11-

5.9mmol/L

Total protein To determine if the

patient experiencing

any alteration that

leads to liver

diseases.

6.2 g/dl 6.4-8.3g/dl 62g/L 64-83g/L

Albumin To diagnose any

cirrhosis,chronic

hepatitis,edema and

ascites.

3.6g/dl 3.4-4.8g/dl 36g/L 34-48g/L

Globulin To diagnose the

presence of any

liver diseases.

2.6g/dl 3.0-3.5 g/dl 26 g/L 30-35 g/L

A/G ratio To determine

chronic liver disease

1.4 g/dl 1.1- 1.8 g/dl 1.4 g/L 1.1-1.8 g/L

Potassium To know if the

patient is prone to

edema.

132.2 mg/dl 3.4-4.0

mg/dl

132.2

mmol/L

3.4-4.0

mmol/L

Chloride To maintain acid

base balance.

7.22 mg/dl 92-102

mg/dl

7.22

mmol/L

92-102

mmol/L


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XVII.EVALUATION

In doing this study, the researcher understand much better what is Chronic

Kidney Disease (CKD).It enhances the knowledge that we should have regarding the

various drugs that are related to treat the disease.

The data that was indicated in this study was obtained by having research,

conducting interview and performing physical assessment. The patients chart was also

used for the other information needed. During the interview the interviewee established

therapeutic communication and took the chance to conduct a health teaching to the

patient as well as to his significant others. The researcher hope that the health teaching

rendered can help the patient and his significant others in the situation that they are

going through. Most of all, the researcher performed the appropriate nursingmanagement to promote patients high optimum level of functioning regardless of

patient condition.


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City of Manila

UNIVERSIDAD DE MANILA

(Formerly City College of Manila)

A. Villegas St. Mehan Garden, Ermita, Manila

In partial fulfillment of the requirement in

Related Learning Experience

Gat Andres Bonifacio Memorial Medical Center Medicine Ward

A Case Study on

CHRONIC KIDNEY DISEASE

Submitted to:

Ms. Sandra Loberiano, RN(Clinical Instructor)

Submitted by:

Glazel JulianJona Lamson

Marlyn LindayaoMelody Lucmayon

Delio ManaoisChristina Marcial

Karissa Claudine MazoMichelle Morales

Jason NuguidAnne Monique Ongjoco

Eleeh Lour PedrazaMichael Stephen Pile

GROUP 3 Nr-31

case pres .med ward

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