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fifth stage, the GFR already falls below 15 mL/min. In this stage, dialysis or kidney
replacement is essential for the survival of the patient.
III. Epidemiology
Globally, Chronic kidney disease (CKD) is a key determinant of the poor health outcomes for major
NCDs. CKD is a worldwide threat to public health, but the size of the problem is probably not
fully appreciated. Estimates of the global burden of the diseases report that diseases of the
kidney and urinary tract contribute with 830 000 deaths annually and 18 867 000 disability-adjusted
life years (DALY), making them the 12th highest cause of death (1.4% of all deaths) and the 17th
cause of disability (1% of all DALY). This ranking is similar across world Bank regions, but,
among developing areas, East Asia and Pacific regions have the highest annual rate of
death due to diseases of the genitourinary system. National and international renal registries offer an important
source of information on several aspects of CKD. In particular, they are useful in characterizing the population
on renal replacement therapy (RRT) due to end-stage renal disease (ESRD), describing the
prevalence and incidence of ESRD and trends in mortality and disease rates. According to this
analysis, the most recent available data indicate that the prevalence of ESRD ranges from 2447 pmp
in Taiwan to 10 pmp in Nigeria. However, there is paucity of renal registries glob ally
with an international standard for registry data collection, especially in low- and middle-income
countries,where, in addition, the use of RRT is scarce or non-existent, eventually making it difficultto compare
ESRD results.
Nationally, Manila,, Philippines In 2003, the Department of Health reported that the prevalence of chronic
kidney disease (CKD) among adult =Filipinos was 2.6 percent(or 2.6 out of 100 adult
Filipinos). Recent research suggests that CKD prevalence ha wo r s e n e d , a f f e c t i n g o n e i n
1 0 a d u l t F i l i p i n o s . I n 2 0 1 4 , t h e N a t i o n a l K i d n e y a n d Transplant Institute
cited kidney failure as the ninth leading cause of death among Filipinos. Consistent
with worldwide statistics, the Philippine Renal Registry reports thatdiabetes is the leading cause
of CKD at 44.6 percent, with hypertension as the runner-up at 4/ percent. Early detection and
treatment can often keep chronic kidney from getting worsen.
IV. Patient data and Health history
A. Demographic
Name of patient: mr. X
Age: 67 y/o
Sex: male
Civil status: married
Educational attainment:college grauduate
Occupation: retired
Religion: roman catholic
Birthday: may 27, 1947
Nationality: Filipino
B. Chief Complaints : Difficulty of Breathing
Initial Diagnosis : Pulmonary Congestion
type 2 DM 20 years
type 2 DM 20 years
F. Allergies
Allergy to Seafoods
V. Physical assessment
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.
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 waste products into the tubule.
The kidneys also produce certain hormones that have important functions in the body, including the
following:
Active form of vitamin D (calcitriol or 1,25 dihydroxy-vitamin D), which regulates absorption
of calcium and phosphorus from foods, promoting formation of strong bone.
Erythropoietin (EPO), which stimulates the bone marrow to produce red blood cells.
Renin, which regulates blood volume and blood pressure. Chronic kidney disease occurs when one
suffers from gradual and usually permanent loss of kidney function over time. This happens gradually,
usually over months to years. Chronic kidney disease is divided into five stages of increasing severity
(see Table 1 below). The term "renal" refers to the kidney, so another name for kidney failure is "renal
failure." Mild kidney disease is often called renal insufficiency.
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), disorders of cholesterol and
fatty acids, and bone disease.
Stage 5 chronic kidney disease is also referred to as kidney failure, end-stage kidney disease, or endstage 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 to stay alive.
Unlike chronic kidney disease, acute kidney failure develops rapidly, over days or weeks.
Acute kidney failure usually develops in response to a disorder that directly affects the kidney,
its blood supply, or urine flow from it.
Acute kidney failure is often reversible, with complete recovery of kidney function.
Some patients are left with residual damage and can have a progressive decline in kidney
function in the future.
Others may develop irreversible kidney failure after an acute injury and remain dialysisdependent.
Table 1. Stages of Chronic Kidney Disease
GFR*
mL/min/1.73 m2
*GFR is glomerular filtration rate, a measure of the kidney's function.
1
Slight kidney damage with normal or increased filtration More than 90
2
Mild decrease in kidney function
60 to 89
3
Moderate decrease in kidney function
30 to 59
4
Severe decrease in kidney function
15 to 29
5
Kidney failure
Less than 15 (or dialysis)
Stage
Description
VII.
Pathophysiology
VIII.
7:00pm
Started Lactulose 30ml once a day at bbedtime
shift esomeprazole to Pantoprazole 40mg/iv
increase midaolam to 1.5ml/hr
apply 2 point restrants
May 27 2015
Changed MV setting to FIO@ 35, PS 12
for cxr ap sitting after HD
decreased duavent neb to every 8hours
Start Vancomycin 500mg every @ days diluted in 100 ml PNSS to run for 1
hour,,
on dialysis days give vancomycin 2grams diluted in 200ml PNSS at
15mg/min over the last 2
hours of dialysis
facilitate BT
continue piperacillin tazobactam
Budesonide 500mcg 1 nebule every 12hours
titrate dopamine drip to Map >65
for cbc tom include na, k , mg
Shifted vancomycin to oxacillin 2grams every 6hours
May 28, 2015
For HD tomorrow (friday), 8hours duration
for 2d echo with DS done
Done ABG
Maintianed MV settings, and o2 sats >94%, for passive leg raise
Start Lactulose 30 ml once daily- hold if with BM 2x a day
shifted pantopraole to lansopraole 30mg/tab once a day per ngt
revise feeding to 1500kcal nephro baased DM 2:1dilution with 20ml flushing
every 4 hours
increased duavent neb to every 6hours
continue suctions thick secretions
maintained present vent setting for now
for abg, lactate tom morning and include cortisol, and phospuros
May 29, 2015
please apply 2 point restraints
for repeat CXR post HD
for rpeat cbc pre HD
please reserve 1u PRBC properly typed and crossmatched for possible
transfusion during HD
Start Hydrocortisone 200mg/iv in 200ml PNSS for 24hours
Facilitate HD
decreased PS to 10
GOAL OF CARE
INTERVENTION
EVALUATION
INEFFECTIVE
AIRWAY
CLEARANCE
RELATED TO (+)
YELLOW THICK
SECRETION
Objective:
-yellowish thick
secretion
-crackles at bilateral
lower segment
-with Endotracheal tube
with closed suction
Auscultate bilateral
lower segment of the
lungs
Elevate head of bed
Turn patient side to side
every 2 hours
Suction secretion as
needed
Administer mucolytics
as prescribed
Perform nebulization as
ordered
Perform
chestphysiotherapy
(back tapping)
PROBLEM
GOAL OF CARE
INTERVENTION
EVALUATION
FLUID VOLUME
EXCESS RELATED
TO PULMONARY
CONGESTION
Objective:
-crackles at bilateral
lower segment
- (+) agitation
(+) drows,
tachypneic ,
Shortness of
breath
BP-111/58
HR 56
RR 28
o2 sats 96%
XII.
Discharge planning
Auscultate bilateral
lower segment of the
lungs
Elevate head of bed
Turn patient side to side
every 2 hours
Monitor input and
output accurately