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Case Study

On
Chronic Kidney Disease
probably to 2°
Hypertension

Submitted by:
Lukban, Cheryl A.
A3BB
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is synonymous with the now outdated terms end-stage renal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.

Objectives

General Objective:

The purpose of this study is to provide deeper


theoretical and practical knowledge and information about chronic
kidney disease.

Specific Objective:

1. To provide information on the related causes of chronic


kidney diseases

2. To provide information regarding postpartum care for


patients who had the similar illness of chronic kidney
disease

3. To provide a framework of study regarding the subject that


can serve as the foundation of future studies and research
Patient Data Profile
Demographic Data
Name: Mrs. X
Age: 75 y/o
Sex: Female
Civil Status: Married
Religion: Roman Catholic
Birth Place: Manila
Birth Date : September 13, 1933

Admission Data
Date and Time of Admission: August 8, 2009 at 10: 45pm
Attending Physician: Dr. Solima
Admission Diagnosis: Chronic Kidney Disease probably 2° to
hypertension

Medical History
2007 – breast removal

Family Medical History


Father’s Side: None
Mother’s Side: None

Social History
Patient’s Occupation: Housewife/tinder
Partner’s Occupation: Carpenter
*partner is deceased
Gordon’s Functional Assessment
Pattern Before During Analysis and
Hospitalization Hospitalization Interpretation
Self Patient felt shePatient feels Normal
Perception- is still strong weak and concern
Self Concept wants to be regarding on
Pattern out of the her body
hospital strength
Role Patient primary Patient primary Patient is
Relationship support are her support are dependent on
Pattern children still her her children
children
Sexuality and Patient Patient still Normal
Reproductive believed she is believed she is reaction on sex
Health too old too old and
reproductive
health because
of her age
Cognitive There are no There are no Normal
Perceptual problem in problem in cognitive
Pattern hearing and hearing and patterns
visual acuity visual acuity
Coping Stress Psychosocial: Psychosocial: Patients
Tolerance display normal
Ego Integrity Ego Integrity
Pattern psychosocial,
Vs Vs psychosexual
Despair Despair and cognitive
development.
Psychosexual: Psychosexual:
Emotional
Genital Genital stability
Cognitive: Cognitive:
Formal Formal
Operational
She still talks
She talks to to her children
her children and friends
and friends
Value Belief She hear mass Patient seek Patient has
Pattern regularly and God’s guidance strong religious
pray the rosary for well being belief.
Elimination Patient use to Patient is place Patient voiding
void 4 times a in folly pattern are
day and catheter and altered due to
regularly defecation of the folly
defecates at stool is altered catheter
least once a inserted
day
Activity Patient prefer Patient cannot Patient activity
Exercise to walk for stand nor is altered
Pattern exercise move here because of
extremities being
and sits on bed bedridden
Sleep Rest The patient The patient Interrupted
Pattern has an average now has sleep during
of 6 hours of irregular hospitalization
continuous pattern of because of
sleep sleep environmental
factors and
hospital
procedure
Safe No allergies No allergies Normal
Environment
Oxygenation
Nutrition Patient able to Patient fluid is Iv fluids are
eat and finish partially given for
one full course supplied hydration. Diet
meal and able intravenously of the patient
to eat any by PNSS 1L x is restricted.
kinds of fruits, 10gtts/min. her
meat and diet is maintain
vegetables. Low salt low
Maximum fat and Na
intake of fluids intake is
is 3-5 glass a limited. She
day. eats 3x a day
but in small
amount. The
maximum
intake of fluid
is 2-3 glass a
day.
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 Henlé. 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 Henlé - 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 Henlé. 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 ½ 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 are 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
Diagnostic Procedures
Urinalysis
August 21, 2009
Macroscopic Microscopic
Light yellow 12-15 / HPF
Color RBC
Transparency Cloudy WBC Many / HPF
Specific 1.015 Epithelial Cells Moderate
Gravity
Reaction 6.0 Mucus Threads Few
Chemical Bacterial Many
Tests Negative Crystals
Many
Sugar A. Urates
Albumin Trace
Special Tests A. Phosphate
Calcium
Foam’s test
Coxalate
Ketone Others
Pregnancy test
Analysis and Interpretation:
Laboratory results revealed that there is presence of albumin in
the blood and no sugar present.

Urinalysis
August 19, 2009
Macroscopic Microscopic
Light yellow 2-3 / HPF
Color RBC
Transparency Slightly WBC 2-3 / HPF
cloudy
Specific 1.020 Epithelial Cells Few
Gravity
Reaction 5.0 Mucus Threads Occasional
Chemical Bacterial Few
Tests +2 Crystals
Moderate
Sugar B. Urates
Albumin +3
Special Tests B. Phosphate
Cast Coarse granular
Foam’s test
3-5 / LPF
Ketone Others Waxy cast 2-4 /
PLF
Analysis and Interpretation:
Laboratory results revealed that there is presence of albumin and
sugarin the urine.
Hematology Received : August 18,
2009
Resul Normal Analysis
t
WBC 10.4 4.0- Normal
11.0x10^9
/L
RBC 2.36 4.0- Result was below normal.
6.0x10^12 This indicates alteration in
/L erythropoietin production
secondary to renal
malfunction.
HGB 70 120-180 Result was below normal.
g/L This shows the decrease in
the oxygen carrying capacity
of the blood secondary low
hematocrit.
HCT 0.22 0.370- Result was below normal,
4 0.540 thus showing anemia related
to insufficient RBC
production.
MCV 94.8 20-100fL Normal
MCH 29.6 27-31pg Normal
MCHC 312 320-360 Result was below normal
g/L
RDW 15.2 11.5-15.0% Normal
Differential
count
01 2-6% Result was below normal
Bands
Segmented 93 50-70% Result was above normal
Lymphocytes 05 20-44% Result is above the normal
range, indicating bacterial
infection.
Monocytes 01 2-9% Result was below normal

August 18,2009
Test Resul Unit Normal Resul U Normal Analysis and
t values ts nit values Interpretation
conv.

Creatini 674 u 53.0 1 11.50 mg 0 1 Result was


ne high mol/ 0 .30 /dl .60 .30 above normal
L thus showing
inability of the
kidney to
excrete
nitrogenous
waste.
Sodium 133 mm 136 14 122.0 mE 13 14 Result was
low ol/L 8 0 q/d 6 8 below normal
l thus showing
the fluid and
electrolyte
imbalance.
Potassiu 2.5 mm 3.65 5 6.30 mE 3 5 Result was
m low ol/L .20 q/d .60 .20 below normal
l thus showing
the fluid and
electrolyte
imbalance.

August 28, 2009


Test Resul Unit Normal Resul U Normal Analysis and
t values t nit values Interpretation
conv.
Creatini 674 u 53.0 1 7.62 mg 0 1 Result was
ne high mol/ 0 .30 /dl .60 .30 above normal
L thus showing
inability of the
kidney to
excrete
nitrogenous
waste.
Sodium 133 mm 136 14 133.0 mE 13 14 Result was
low ol/L 8 0 q/d 6 8 below normal
l thus showing
the fluid and
electrolyte
imbalance.
Potassiu 2.5 mm 3.65 5 2.50 mE 3 5 Result was
m low ol/L .20 q/d .60 .20 below normal
l thus showing
the fluid and
electrolyte
imbalance.
Discharge Planning

M- Medication
➢ Instructed to complied strictly with the following home
medications
➢ Vitamin B Complex I tab OD PO
➢ CaCO I tab TID PO
➢ NaHCO3 I tab TID PO
➢ JNH-RIF-PZO-IHN I tab OD PO

E- Exercise
➢ Encourage mild exercise

T- Treatment
➢ Advice patient to avoid stress related factors

H – Health teachings
➢ Encourage deep breathing exercise
➢ Adequate bed rest

O- Out patient
➢ Informed client to follow up check up
➢ Emphasize the need to be present in medical
procedures schedule

D- Diet
➢ Maintain on low salt low fat diet
➢ Limit fluid intake
Evaluation
This case study attempted to provide complete information about
the illness regarding the patient. There were theoretical and
practical limitations to the study and one important defiecncy was
the author’s relative inexperience in developing a complete case
study. Nevertheless, the information included in this paper was
thoroughly studied and researched and in accordance with the
prescribed requirements.

This study has completely met the objective in providing


information about chronic kidney disease and postpartum care. It
also provide framework of study regarding the topic discuss.

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