SURIGAO EDUCATION CENTER

College of Allied Medical Sciences

Nursing Department
Surigao City

A CASE PRESENTATION

OF

CHRONIC KIDNEY DISEASE

Prepared by:

Jomari Jones Q. Zapanta

Samantha Lie Catherine A. Gibertas

Jonahville E. Almongguera

Nel Marison F. Ensomo

Presented to:

Mrs. Rocelyn S. Dawsan, RN

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 TABLE OF CONTENTS

 Dedication 4
 Acknowledgement 5
 Introduction 6

 Review of Related Literature 8

 Nursing Health History 10

 Biographic Data
 Admission Data
 History of Present Illness 11
 Past Health History
 Childhood Illness
 Childhood Immunization
 History of Hospitalization
 Medical History
 Surgical History
 Accidents and Injuries
 Obstetrical History
 Sexual History 12
 Allergies
 Family Health History
 Personal Habits
 Diet
 Sleep/Rest pattern 13
 Elimination Pattern
 Social Data
 Family Relationship/Friendship
 Educational History
 Occupational History
 Economic Status
 Patterns of Health Care
 Review of System 15
 Integumentary System
 Respiratory System
 Cardiovascular System
 Genitourinary System

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  Gastrointestinal System
 Reproductive System 16
 Musculoskeletal System
 Endocrine System
 Circulatory System
 Neurologic System
 Physical Examination 17
 Skin
 Hair
 Nails
 Skull and Face
 Eyes 18
 Ears
 Nose
 Mouth and Throat
 Neck
 Thorax and lungs 19
 Breast and axillae
 Abdomen
 Upper extremities
 Lower extremities
 Clinical Laboratory 20
 Hematology
 Urinalysis
 Anatomy and Physiology 22

 Drug Study 27

 Pathophysiology 36

 Nursing Care Plan 38

 Discharge Plan 48
 IVF Sheet 50
 I and O sheet
 Vital signs 51
 Definition of Terms 52
 References 53
 Appendices 54

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 DEDICATION

The student nurses who are members of working group assigned in

this particular actual medical care and assistance to analysis ,
and subsequently in its final documentation, wish to confer the
fruits of their mental and physical labor, firstly to the
Almighty Creator for His Holy inspiration in the preparation of
this academic endeavor;

Although physically tiresome yet mentally

interesting, every learning process was seriously and carefully
considered in its minutest detail because such assignment
involved a patient’s full recovery from ailment to healthy human
life;

Secondly we wish to dedicate our accomplishment to

each and every lovable parent’s and guardian of the student
nurses, who patiently extended material support and nurturing
advice that without which, everything would be impossible
finish;

Finally, to our medical mentors, hospital staff, and

co-students of this academic level the flying colors of
recognition and excellence shall be due to them, for their daily
professional lecture cognizant of their erudition, coupled with
happy gestures of camaraderie and friendship in the work
assignment.

This is the teamwork-result of unity from many minds

rolled up into one reading materials that shall serve as a
future reference of similar application.

4
 ACKNOWLEDGEMENT

First of all, the presenters would like to thank GOD

for his guidance, gift of wisdom and strength.

We would like to express our heartily and sincere

appreciation to all the persons and agencies for their support,
expertise and unending encouragement in the preparation of this
case presentation.

Special Thanks to our parents for the continued

financial support and unending words of encouragements, to our
group mates for being cooperative from the beginning up to the
end of making this case presentation plan, to the family of our
patient for their approval and being cooperative and allowing us
to present the medical case.

Thanks to all the clinical instructors for teaching

and giving us all the detailed information and providing us
lectures properly, shared clinical expertise, made suggestion
and recommendation for the success of this CP plan and all
nurses for sharing to us their thoughts and knowledge. Your
contributions are appreciated.

5
 INTRODUCTION

Within our duty in Surigao Medical Center, we received

patient Y having a chronic kidney disease (CKD). He`s 63 years
old, married, a farmer, and Roman Catholic he was born in P-2
STO. NINO, BASILISA. Confidently answered questions. Relating
the stated documentation from the chart, patient Y is suitable
case to be studied.
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. The two main causes of chronic
kidney disease are diabetes and high blood pressure, which are
responsible for up to two-thirds of the cases. Diabetes happens
when your blood sugar is too high, causing damage to many organs
in your body, including the kidneys and heart, as well as blood
vessels, nerves and eyes. High blood pressure, or hypertension,
occurs when the pressure of your blood against the walls of your
blood vessels increases. If uncontrolled, or poorly controlled,
high blood pressure can be a leading cause of heart attacks,
strokes and chronic kidney disease.
Also, chronic kidney disease can cause high blood pressure.
30 million American adults have CKD and millions of others are
at increased risk.
Early detection can help prevent the progression of kidney
disease to kidney failure. Most people may not have any severe
symptoms until their kidney disease is advanced. However, you
may notice that you feel more tired and have less energy, have
trouble concentrating, have a poor appetite, have trouble
sleeping, have muscle cramping at night, have swollen feet and
ankles, have puffiness around your eyes, especially in the
morning, have dry, itchy skin, need to urinate more often,
especially at night.

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 We choose this case because we want to know more about
chronic kidney disease the causes, signs and symptoms,
complications and to have further knowledge of how to treat and
prevent chronic kidney disease.

7
 REVIEW OF RELATED LITERATURE

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. 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).

The two main causes of chronic kidney disease are diabetes

and high blood pressure, which are responsible for up to two-
thirds of the cases. Diabetes happens when your blood sugar is
too high, casing damage to many organs in your body including
the kidneys and heart, as well as blood vessels increases. If
uncontrolled, or poorly controlled, high blood pressure can be a
leading cause of hears attacks, strokes and chronic kidney
disease. Also, chronic kidney disease can cause high blood
pressure.

A person with stage 1 chronic kidney disease (CKD) has kidney

damage with a glomerular filtration rate (GFR) at a normal or
high level greater than 90 ml/min. There are usually no symptoms
to indicate the kidneys are damaged. Because kidneys do a good
job even when they’re not functioning at 100 percent, most
people will not know they have stage 1 CKD. If they do find out

8
they’re in stage 1, it’s usually because they were being tested
for another condition such as diabetes or high blood
pressure (the two leading causes of kidney disease). Other ways
a person may discover they are in sage 1 CKD are: Higher than
normal levels of creatinine or urea in the blood, Blood or
protein in the urine, Evidence of kidney damage in an MRI, CT
scan, ultrasound or contrast X-ray, A family history of
polycystic kidney disease (PKD).

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NURSING HEALTH HISTORY

Biographic Data:

Hospital : Surigao Medical Center

Case No. : 81481
Ward : Male Ward
Name of Patient : Patient Y
Age : 63 years old
Sex : Male
Civil Status : Married
Address : P-2 STO. NINO, BASILISA
Occupation : FARMER
Date of Birth : May 25, 1954
Religion : ROMAN CATHOLIC
Height : 5”9
Weight : 92

Admission Data:

Mode of Transmission : Ambulatory

Date and Time of Admission : October 27, 2017
Vital Signs upon admission
 Heart Rate : 74bpm
 Respiratory Rate : 26cpm
 Blood Pressure : 200/120
 Body Temperature : 36.3

Admitting Physician : Reynaldo E. Tan, MD

Attending Physician : Reynaldo E. Tan, MD
Chief Compliant : Lower Left Quadrant pain, Bipedal
edema
Impression : UTI, CKD
Final Diagnosis8 : Chronic Kidney Disease, Obstructive
uro pathy

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HISTORY OF PRESENT ILLNESS

Four days prior admission patient had experienced severe

back pain on his left lower quadrant associated with his lower
extremities, the patient was self-medicated with herbal
medications such as “sagbong” which did not provide any relief.
He seeks medical attention because he cannot tolerate the pain.
This was also associated with loss of appetite and nausea.

PAST HEALTH HISTORY

I- Childhood Illness

Patient did experienced chickenpox and mumps at age of

12, and measles at age four. His parents did not bring him to
the hospital or health center but they give him herbal
medications as they practice.

II – Childhood Immunization

Patient was not able to recall any of his immunization. He said,

“waya man ko kadumdum mam kun nabakunahan ba ako.”

HISTORY OF HOSPITALIZATION

III- Medical History

No known previous hospitalization as stated by the

patient.

IV – Surgical History

Patient stated that he did not undergo any surgical

procedures.

V- Accidents and Injuries

Patient verbalized that he had no history of any type of

accidents, But minimal injuries like wound from a knife was
experienced by him that do not took a longer period of time for
healing, when he was a child
VI-Sexual History

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 The patient is satisfied about his sex life.

VII-Allergies

Patient has no known allergies to food and drugs as he

claimed.

VIII- Family Health History

Patient’s father died at age of 80 due to hypertension. His

mother died at age of 78 due to diabetes. There are 6 children (
4 boys and 2 girls) in his family and he is the 6th child. Two of
them are still alive( 6th and 5th child) and the rest (4 siblings)
are died due to diabetes and hypertension. His wife and his
children have no known illnesses.

IX- Personal Habits

Patient verbalized, “ Mu inom gyud ko ug mu sigarilyo mga

napuyo ka stick kada adlaw sa una mga 20 pako.” When asked what
kind of alcohol he drinks and cigarettes he used, he said, “
kanang kasaganran gud na imnunon sama sa Tanduay ug red horse og
ako sigarilyo kanang Hope ug marlboro, pero karon hinay hinay
naku ug inom ug sigarilyo tag duha rakan kada adlaw.”

X – Diet/Nutritional Pattern

Patient eats three meals in a day. His usual meal consists of 2

cups of rice with salt, dread salty fish, salted fish he called
“ginamos” with salt, meat with fats and vegetables. He eats
“ginamos” 3x a day. He also eats vegetables and sometimes takes
his snacks usually bread, biscuits and soft drinks such as coke
and pepsi. He has no known food allergies.

At the hospital, his usual meal consists of 2 cups of

rice, fish and meat, with vegetables and also drinks 2 glasses
of water(300ml/glass) during hospital stay.
XI- Sleep/Rest pattern

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He has no problem in sleeping. He usually sleeps at 7pm and
wakes up at 8am during and after hospital stay. He means of
relaxation is through watching T.V, having nap time during
afternoon.

XII-Elimination Pattern

Before and during hospitalization, patient usually defecates

once a day and urinates 3 times a day he also experienced pain
upon urination. He stated that sometimes his urine is reddish
color. Stool is soft to touch and color brown as verbalized by
him.

SOCIAL DATA

XIII-Family Relationship/Friendship

Patient has a good relationship with his family, relatives and

neighbors. His family has been so supportive all throughout this
time when he needs them.

XIV- Educational History

Patient attended elementary until 3rd grade because they have

financial problem that time and he also having difficulty in
understanding Mathematics and English.

XV- Occupational History

According to the patient he started working in farm at the

age of 18 until he had a family he’s still a farmer.

XVI- Economic Status

Patient’s income is from their farm (rice field). His 1st

child is helping him on paying medical bills since his other
children doesn’t have work yet and the Philhealth Insurance from
being indigent helps lowered the total bills as well as the
Senior Citizen discount.
Patterns of Health Care

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 Patient said, when one of the family members gets sick,
they used herbal medicines and often go to “Manambayon”. They
seldom seek medical help from the doctor.

Psychological Data

The major stressor of the patient is financial in nature.

He is worried about his present illness but he is more worried
of the expenses that his family is spending on the medicines and
hospital bills.

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REVIEW OF SYSTEM

INTEGUMENTARY SYSTEM
 No history of skin infection as claimed
 With history of dandruff
 Brown skin complexion
 Patient has intact skin with good skin turgor
 Swelling on his lower extremities and part of his faces
 Skin is warm to touch
 Patient has no lesion

RESPIRATORY SYSTEM
 No complaints of weaknesses on simple activity.
 No appearance of difficulty in breathing
 Has no history of pneumonia
 No abnormality sounds upon auscultation

CARDIOVASCULAR SYSTEM

 Patient complains some weaknesses.

 Patient is hypertensive
 With history of hypertension, as claimed
 Patient’s usual blood pressure is 160/90
 Patient’s pulse rate is 73 beat per minute

GENITOURINARY SYSTEM
 Urinates 4 times a day as claimed by the patient.
 Patient experienced pain upon voiding.
 Color of the urine is yellow.
 Urine transparency is slightly hazy.
 Protein trace in urinalysis.

GASTROINTESTINAL SYSTEM
 With no complaints of constipation as stated by the
patient.
 Patient has no abnormality in defecating
 No abnormal bowel sounds, as claimed
 Patient With no history of hemorrhoids and rectal bleeding.

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REPRODUCTIVE SYSTEM
 Satisfaction to sex life was experienced as claimed by him.
 Patient is impotence, as claimed
 No history of STD.

MUSCULOSKELETAL SYSTEM
 With complaints of weakness.
 With complaints of fatigue.
 With complaints of lower back pain
 No history of fracture or any injury

ENDOCRINE SYSTEM
 No mass noted.
 No thyroid problem
 No Nodules noted

CIRCULATORY SYSTEM
 With no history of painful tonsils.
 With no history of having nodules on the neck
 No history of bleeding problems
 Patient is hypertensive.
 With history of hypertension.

NEUROLOGIC SYSTEM
 Patient is conscious to time, place and people
 Has no history of seizure

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PHYSICAL EXAMINATION

Skin

Inspection
 Has a brown complexion
 Has closed intact skin
 No lesions
 Edema at lower extremities
Palpation
 Skin is warm to touch
 Non-pitting edema at lower extremities
 Poor skin turgor

Hair
Inspection
 Color of hair is black
 No infestation of parasites
 With dandruff

Nails
Inspection
 White nail bed
 Nails has the shape of convex curve
Palpation
 No capillary refill
 Edematous

Skull and face

Inspection
 Facial skin uniform in color
 Normal facial movement
 No lesions
 Skull shape is round and symmetric

Eyes
Inspection
 Both eyes were symmetrical

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  Eyelashes equally distributed, curled slightly outward
 Pupils are equally rounded
 The pupil was brown in color with white conjunctiva
 Blinking reflex was normal and functional
 Peripheral reflexes are normal and functional
 Patient is farsighted
 Patient is using reading glasses

Ears
Inspection
 Auricles same color as facial skin, symmetrical and are
aligned with outer canthus of eye
 Pinna recoils after it is folded
 No cerumen
 Able to hear spoken words clearly
 No discharges

Nose
Inspection
 Has the same color as facial skin
 Not tender, no lesion
 No discharges
 Straight and symmetrical
 Able to identify odors like alcohol, cologne and coffee

Mouth and throat

Inspection
 Lips is brown
 Lips are symmetrical
 Tongue is light pink in color
 Tongue moves freely
 With dental caries and decayed lower molars
 Gums is light pink in color
 Uvula is position in the midline of soft palate

Neck
Inspection
 Neck positioned at the midline

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  Brown in color
Palpation

 Without tenderness and reflexes easily

 No masses

Thorax and Lungs

Inspection
 Chest movement is apparent during inhaling and exhaling
Palpation
 No pain when palpated

Breast and Axillae

Inspection
 Skin uniform in color
 Nipples at the same level and protrude slightly
 Breast is even with the chest wall

Abdomen
Inspection
 Symmetrical contour and uniform in color
 No rashes or lesions
 Ascites (115cm)
Auscultation
 Bowel sounds are normal (within 5-30 gurgles/minute)

Upper Extremities
Inspection
 Edematous in the arms and hands
Palpation
 Non-pitting edema
 No capillary refill in nails

Lower Extremities
Inspection
 Edematous
Palpation
 Non-pitting edema

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 CLINICAL LABORATORY
Oct. 27,2017 BLOOD CHEMISTRY

TEST RESULT REFERENCE/UNIT SIGNIFICANCE

CREATININE 19.7 (H) 0.73-1.36 INCREASED
mg/dl
URIC ACID 6.70 3.36-7.06 mg/dl NORMAL
BLOOD UREA 29.1 (H) 1.70-8.30 HIGH
NITROGEN mmol/1L
SODIUM 129.0 (L) 135.00-148.00 HYPONATREMIA
mmol/L
POTASSIUM 5.30 (H) 3.50-5.30 NORMAL
mmol/L
CAPILLARY BLOOD 96.0 70.00-120.00 NORMAL
SUGAR mg/dl

URINALYSIS

Normal Significance
Value
COLOR YELLOW WBC TNTC /HPF Amber Normal
TRANSPARENCY SLIGHTLY RBC 0-2 /HPF Clear Infection
HAZY
PROTEIN TRACE EPITHELIAL MODERATE Proteinuria
CELLS
Ph 6.0 CASTS /LPF 4.5 - 8.0 Slightly Acidic
SPECIFIC 1.020 CRYSTALS 1.005- Normal
GRAVITY 1.035
GLUCOSE NEGATVE BACTERIA FEW 0- Normal
MUCOUS 0.8mmol/L
THREAD
ASCORBIC ACID OTHERS

BILIRINUBIN
UROBINOGEN
KETONES
NITRATE
LEUKOCYTES

PREGNANCY

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Oct. 28,2017
BLOOD CHEMISTRY

TEST RESULT REFERENCE/UNIT SIGNIFICANCE

TOTAL CHOLESTEROL 162 0.00-200.00 mg/dl NORMAL
TRIOLYCERIDES 102 43.80-183.80 NORMAL
mg/dl
DL-CHOLESTEROL 39.2 35.00-55.00 mg/dl NORMAL
DL-CHOLESTEROL 102 0.00-150.00 mg/dl NORMAL

21
 Anatomy and physiology

The kidneys are a pair of bean-

shaped organs found along the posterior
wall of the abdominal cavity. The left
kidney is located slightly higher than
the right kidney because the right side
of the liver is much larger than the
left side. The kidneys, unlike the
other organs of the abdominal cavity,
are located posterior to the peritoneum
and touch the muscles of the back. The
kidneys are surrounded by a layer of
adipose that holds them in place and
protects them from physical damage. The
kidneys filter metabolic wastes, excess
ions, and chemicals from the blood to
form urine.

Ureters
The ureters are a pair of tubes that carry urine from the
kidneys to the urinary bladder. The ureters are about 10 to 12
inches long and run on the left and right sides of the body
parallel to the vertebral column. Gravity and peristalsis of
smooth muscle tissue in the walls of the ureters move urine
toward the urinary bladder. The ends of the ureters extend
slightly into the urinary bladder and are sealed at the point of
entry to the bladder by the ureterovesical valves. These valves
prevent urine from flowing back towards the kidneys.

Urinary Bladder
The urinary bladder is a sac-like hollow organ used for the
storage of urine. The urinary bladder is located along the
body’s midline at the inferior end of the pelvis. Urine entering
the urinary bladder from the ureters slowly fills the hollow
space of the bladder and stretches its elastic walls. The walls
of the bladder allow it to stretch to hold anywhere from 600 to
800 milliliters of urine.

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Urethra
The urethra is the tube through which urine passes from the
bladder to the exterior of the body. The female urethra is
around 2 inches long and ends inferior to the clitorisand
superior to the vaginal opening. In males, the urethra is around
8 to 10 inches long and ends at the tip of the penis. The
urethra is also an organ of the male reproductive system as it
carries sperm out of the body through the penis. The flow of
urine through the urethra is controlled by the internal and
external urethral sphincter muscles. The internal urethral
sphincter is made of smooth muscle and opens involuntarily when
the bladder reaches a certain set level of distention. The
opening of the internal sphincter results in the sensation of
needing to urinate. The external urethral sphincter is made of
skeletal muscle and may be opened to allow urine to pass through
the urethra or may be held closed to delay urination.

Maintenance of Homeostasis
The kidneys maintain the homeostasis of several important
internal conditions by controlling the excretion of substances
out of the body.
Ions. The kidney can control the excretion of potassium, sodium,
calcium, magnesium, phosphate, and chloride ions into urine. In
cases where these ions reach a higher than normal concentration,
the kidneys can increase their excretion out of the body to
return them to a normal level. Conversely, the kidneys can
conserve these ions when they are present in lower than normal
levels by allowing the ions to be reabsorbed into the blood
during filtration. (See more about ions.)

pH
The kidneys monitor and regulate the levels of hydrogen
ions (H+) and bicarbonate ions in the blood to control blood pH.
H+ ions are produced as a natural byproduct of the metabolism of
dietary proteins and accumulate in the blood over time. The
kidneys excrete excess H+ ions into urine for elimination from
the body. The kidneys also conserve bicarbonate ions, which act
as important pH buffers in the blood.

23
Osmolarity.
The cells of the body need to grow in an isotonic
environment in order to maintain their fluid and electrolyte
balance. The kidneys maintain the body’s osmotic balance by
controlling the amount of water that is filtered out of the
blood and excreted into urine. When a person consumes a large
amount of water, the kidneys reduce their reabsorption of water
to allow the excess water to be excreted in urine. This results
in the production of dilute, watery urine. In the case of the
body being dehydrated, the kidneys reabsorb as much water as
possible back into the blood to produce highly concentrated
urine full of excreted ions and wastes. The changes in excretion
of water are controlled by antidiuretic hormone (ADH). ADH is
produced in the hypothalamus and released by the
posterior pituitary gland to help the body retain water.

Blood Pressure. The kidneys monitor the body’s blood pressure to

help maintain homeostasis. When blood pressure is elevated, the
kidneys can help to reduce blood pressure by reducing the volume
of blood in the body. The kidneys are able to reduce blood
volume by reducing the reabsorption of water into the blood and
producing watery, dilute urine. When blood pressure becomes too
low, the kidneys can produce the enzyme renin to constrict blood
vessels and produce concentrated urine, which allows more water
to remain in the blood.

Filtration
Inside each kidney are around a million tiny structures
called nephrons. The nephron is the functional unit of the
kidney that filters blood to produce urine. Arterioles in the
kidneys deliver blood to a bundle of capillaries surrounded by a
capsule called a glomerulus. As blood flows through the
glomerulus, much of the blood’s plasma is pushed out of the
capillaries and into the capsule, leaving the blood cells and a
small amount of plasma to continue flowing through the
capillaries. The liquid filtrate in the capsule flows through a
series of tubules lined with filtering cells and surrounded by
capillaries. The cells surrounding the tubules selectively
absorb water and substances from the filtrate in the tubule and
return it to the blood in the capillaries. At the same time,
waste products present in the blood are secreted into the

24
filtrate. By the end of this process, the filtrate in the tubule
has become urine containing only water, waste products, and
excess ions. The blood exiting the capillaries has reabsorbed
all of the nutrients along with most of the water and ions that
the body needs to function.

Storage and Excretion of Wastes

After urine has been produced by the kidneys, it is
transported through the ureters to the urinary bladder. The
urinary bladder fills with urine and stores it until the body is
ready for its excretion. When the volume of the urinary bladder
reaches anywhere from 150 to 400 milliliters, its walls begin to
stretch and stretch receptors in its walls send signals to
the brain and spinal cord. These signals result in the
relaxation of the involuntary internal urethral sphincter and
the sensation of needing to urinate. Urination may be delayed as
long as the bladder does not exceed its maximum volume, but
increasing nerve signals lead to greater discomfort and desire
to urinate.
Urination is the process of releasing urine from the urinary
bladder through the urethra and out of the body. The process of
urination begins when the muscles of the urethral sphincters
relax, allowing urine to pass through the urethra. At the same
time that the sphincters relax, the smooth muscle in the walls
of the urinary bladder contract to expel urine from the bladder.

Production of Hormones
The kidneys produce and interact with several hormones that
are involved in the control of systems outside of the urinary
system.

Calcitriol.
Is the active form of vitamin D in the human body. It is
produced by the kidneys from precursor molecules produced by UV
radiation striking the skin. Calcitriol works together with
parathyroid hormone (PTH) to raise the level of calcium ions in
the bloodstream. When the level of calcium ions in the blood
drops below a threshold level, the parathyroid glands release
PTH, which in turn stimulates the kidneys to release calcitriol.
Calcitriol promotes the small intestineto absorb calcium from
food and deposit it into the bloodstream. It also stimulates the

25
osteoclasts of the skeletal system to break down bone matrix to
release calcium ions into the blood.

Erythropoietin
Erythropoietin, also known as EPO, is a hormone that is
produced by the kidneys to stimulate the production of red blood
cells. The kidneys monitor the condition of the blood that
passes through their capillaries, including the oxygen-carrying
capacity of the blood. When the blood becomes hypoxic, meaning
that it is carrying deficient levels of oxygen, cells lining the
capillaries begin producing EPO and release it into the
bloodstream. EPO travels through the blood to the red bone
marrow, where it stimulates hematopoietic cells to increase
their rate of red blood cell production. Red blood cells contain
hemoglobin, which greatly increases the blood’s oxygen-carrying
capacity and effectively ends the hypoxic conditions.

Renin
Renin is not a hormone itself, but an enzyme that the kidneys
produce to start the renin-angiotensin system (RAS). The RAS
increases blood volume and blood pressure in response to low
blood pressure, blood loss, or dehydration. Renin is released
into the blood where it catalyzes angiotensinogen from the liver
into angiotensin I. Angiotensin I is further catalyzed by
another enzyme into Angiotensin II.

Angiotensin II stimulates several processes, including

stimulating the adrenal cortex to produce the hormone
aldosterone. Aldosterone then changes the function of the
kidneys to increase the reabsorption of water and sodium ions
into the blood, increasing blood volume and raising blood
pressure. Negative feedback from increased blood pressure
finally turns off the RAS to maintain healthy blood pressure
levels.

26
 DRUG STUDY 1

Generic Name: furosemide

Brand Name: Lasix

Classification: Loop diuretic

Dosage & Route:

Available forms: Tablets—20, 40, 80 mg; oral solution—10 mg/mL,

40 mg/5 mL; injection—10 mg/mL.

Indications:

Oral, IV: Edema associated with CHF, cirrhosis, renal disease

IV: Acute pulmonary edema

Oral: Hypertension

Actions

Rapid-acting potent sulfonamide “loop” diuretic and

antihypertensive with pharmacologic effects and uses almost
identical to those of ethacrynic acid. Exact mode of action not
clearly defined; decreases renal vascular resistance and may
increase renal blood flow.

Contraindications:

History of hypersensitivity to furosemide or sulfonamides

increasing oliguria, anuria, fluid and electrolyte depletion
states,hepatic coma; pregnancy (category C), lactation.

Adverse effects

CV: Postural hypotension, dizziness with excessive diuresis,

acute hypotensive episodes, circulatory collapse.

Metabolic: Hypovolemia, dehydration, hyponatremia, hypokalemia,

hypochloremia metabolic alkalosis, hypomagnesemia, hypocalcemia
(tetany), hyperglycemia, glycosuria, elevated BUN,
hyperuricemia;.

27
GI: Nausea, vomiting, oral and gastric burning, anorexia,
diarrhea, constipation, abdominal cramping, acute pancreatitis,
jaundice.

Urogenital: Allergic interstitial nephritis, irreversible renal

failure, urinary frequency.

Hematologic: Anemia, leukopenia, thrombocytopenic purpura;

aplastic anemia, agranulocytosis (rare).

Special Senses: Tinnitus, vertigo, feeling of fullness in ears,

hearing loss (rarely permanent), blurred vision.

Skin: Pruritus, urticaria, exfoliative dermatitis, purpura,

photosensitivity, porphyria cutanea tarde, necrotizing angiitis
(vasculitis).

Body Whole: Increased perspiration; paresthesias; activation of

SLE, muscle spasms, weakness; thrombophlebitis, pain at IM
injection site.

Nursing implications

Observe patients receiving parenteral drug carefully; closely

monitor BP and vital signs. Sudden death from cardiac arrest has
been reported.

Monitor BP during periods of diuresis and through period of

dosage adjustment.

Observe older adults closely during period of brisk diuresis.

Sudden alteration in fluid and electrolyte balance may
precipitate significant adverse reactions. Report symptoms to
physician.

Lab tests: Obtain frequent blood count, serum and urine

electrolytes, CO2, BUN, blood sugar, and uric acid values during
first few months of therapy and periodically thereafter.

Monitor for S&S of hypokalemia .

Monitor I&O ratio and pattern. Report decrease or unusual

increase in output. Excessive diuresis can result in dehydration
and hypovolemia, circulatory collapse, and hypotension. Weigh
patient daily under standard conditions.

28
Monitor urine and blood glucose & HbA1C closely in diabetics and
patients with decompensated hepatic cirrhosis. Drug may cause
hyperglycemia.

Note: Excessive dehydration is most likely to occur in older

adults, those with chronic cardiac disease on prolonged salt
restriction, or those receiving sympatholytic agents.

29
 DRUG STUDY 2

Generic Name: Clonidine hydrochloride

Brand Names: Apo-Clonidine (CAN) or Cat après

Classification: Analgesic (Duraclon )

Indications:

Hypertension, used alone or as part of combination therapy

Treatment of severe pain in cancer patients in combination with

opiates; epidural more effective with neuropathic pain
(Duraclon).

Contraindications and cautions:

Contraindicated with hypersensitivity to clonidine or any

adhesive layer components of the transdermal system.

Use cautiously with severe coronary insufficiency, recent MI,

cerebrovascular disease; chronic renal failure; pregnancy,
lactation.

Adverse effects

CNS: Drowsiness, sedation, dizziness, headache, fatigue that

tend to diminish within 4–6 wk, dreams, nightmares, insomnia,
hallucinations, delirium, nervousness, restlessness, anxiety,
depression, retinal degeneration

CV: CHF, orthostatic hypotension, palpitations, tachycardia,

bradycardia, Raynaud’s phenomenon, ECG abnormalities manifested
as Wenckebach period or ventricular trigeminy

Dermatologic: Rash, angioneurotic edema, hives, urticaria, hair

thinning and alopecia, pruritus, dryness, itching or burning of
the eyes, pallor

GI: Dry mouth, constipation, anorexia, malaise, nausea,

vomiting, parotid pain, parotitis, mild transient abnormalities
in liver function tests

GU: Impotence, decreased sexual activity, diminished libido,

nocturia, difficulty in micturition, urinary retention

30
Other: Weight gain, transient elevation of blood glucose or
serum creatine phosphokinase, gynecomastia, weakness, muscle or
joint pain, cramps of the lower limbs, dryness of the nasal
mucosa, fever

Nursing considerations

Assessment:

History: Hypersensitivity to clonidine or adhesive layer

components of the transdermal system; severe coronary
insufficiency, recent MI, cerebrovascular disease; chronic renal
failure; lactation, pregnancy

Physical: Body weight; T; skin color, lesions, temperature;

mucous membranes—color, lesion; breast examination; orientation,
affect, reflexes; ophthalmologic examination; P, BP, orthostatic
BP, perfusion, edema, auscultation; bowel sounds, normal output,
liver evaluation, palpation of salivary glands; normal urinary
output, voiding pattern; liver function tests, ECG

31
 DRUG STUDY 3

Generic Name: Sodium Bicarbonate

Brand Name: Sodium Bicarbonate

Classifications: gastrointestinal agent; antacid; fluid and

electrolyte balance agent

Actions

Short-acting, potent systemic antacid. Rapidly neutralizes

gastric acid to form sodium chloride, carbon dioxide, and water.
After absorption of sodium bicarbonate, plasma alkali reserve is
increased and excess sodium and bicarbonate ions are excreted in
urine, thus rendering urine less acid. Not suitable for
treatment of peptic ulcer because it is short-acting, high in
sodium, and may cause, gastric, distention, systemic, alkalosis,
and possibly acid-rebound.

Contraindications:

Prolonged therapy with sodium bicarbonate; patients losing

chloride (as from vomiting, GI suction, diuresis); heart
disease, hypertension; renal insufficiency; peptic ulcer.

Route & dosage

Antacid
Adult:PO 0.3–2 g 1–4 times/d or 1/2 tsp of powder in glass of
water
Urinary Alkalinizer

Adult:PO 4 g initially, then 1–2 g q4h

Child:PO 84–840 mg/kg/d in divided doses

Cardiac Arrest

Adult:IV 1 mEq/kg of a 7.5% or 8.4% solution initially, then 0.5

mEq/kg q10min depending on arterial blood gas determinations
(8.4% solutions contain 50 mEq/50 mL), give over 1–2 min

Child:IV 0.5–1 mEq/kg of a 4.2% solution q10min depending on

arterial blood gas determinations, give over 1–2 min

32
Metabolic Acidosis

Adult:IV 2–5 mEq/kg by IV infusion over 4–8 h

Infant:IV 2–3 mEq/kg/d of a 4.2% solution over 4–8 h

Adverse effects

GI:Belching, gastric distention, flatulence.

Metabolic:Metabolic alkalosis; electrolyte imbalance: sodium

overload (pulmonary edema), hypocalcemia (tetany), hypokalemia,
milk-alkali syndrome, dehydration.

other:Rapid IV in neonates (Hypernatremia, reduction in CSF

pressure, intracranial hemorrhage).

Skin:Severe tissue damage following extravasation of IV

solution.

Urogenital:Renal calculi or crystals, impaired kidney function.

Nursing implications

Be aware that long-term use of oral preparation with milk or

calcium can cause milk-alkali syndrome: Anorexia, nausea,
vomiting, headache, mental confusion, hypercalcemia,
hypophosphatemia, soft tissue calcification, renal and ureteral
calculi, renal insufficiency, metabolic alkalosis.

Lab tests: Urinary alkalinization: Monitor urinary pH as a guide

to dosage (pH testing with nitrazine paper may be done at
intervals throughout the day and dosage adjustments made
accordingly).

Lab tests: Metabolic acidosis: Monitor patient closely by

observations of clinical condition; measurements of acid-base
status (blood pH, Po2, Pco2, Hco3-, and other electrolytes, are
usually made several times daily during acute period).

Observe for signs of alkalosis (over treatment)

Observe for and report S&S of improvement or reversal of

metabolic acidosis

33
 DRUG STUDY 4

Generic Name: Calcium Carbonate

Brand Name: Calcium Salts

Classifications:

Therapeutic: mineral and electrolytes supplements

Indication:

PO,IV: Treatment and prevention of hypocalcaemia

PO: Emergency treatment of hyperkalemia and hypermagnesemia and

adjunct in cardiac arrest or calcium blocking agent toxicity.

Actions

Essential for nervous, muscular and skeletal system. Maintain

cell membrane and capillary permeability. Act as an activator in
transmission of nerve impulses and contraction of cardiac,
skeletal, and smooth muscle.

Contraindications:

Contraindication in Hyperkalemia, Renal calculi, Ventricular,

fibrillation.

Adverse reaction:

CNS: Syncope, tingling

CV: Cardiac arrest, arrhythmias, bradycardia.

GI: Constipation, nausea, vomiting

GU: calculi, hypercalciuria

Nursing implications

Assessment:

 Monitor blood pressure, pulse and ECG frequently

throughout parenteral.

34
 Assess IV site patency. Extra venous may cause
cellulitis, and sloughing.
 Monitor patient on digitalis for signs of toxicity.
 Antacid: when used an antacid, assess for heartburn
and abdominal pain.
Inspect abdomen: auscultate bowel sounds

35
 PATHOPHYSIOLOGY

Precipitating factors:
 High sodium intake
Predisposing factors:
 Hypertensive
Age: 63 V
 Alcohol consumption
Gender: Male
 Smoking

Decreased of nephron number

Hyperfiltration at glomerulus

Increased of renin Increased of single

Increased Glomerular
angiotensin aldosterone nephron GFR
Permeability
system

Increased filtration of Hypertension

proteins and
macromolecules

Proteinuria
Trace
160/100
Nephrotoxic inflammation

Dyslipidemia Normal

Tubulointerstitial fibrosis

Obstructive uropathy

36
Decreased GFR Decreased urine output Systemic complications

Hgb: 5.59 ( )
Anemia RBC: 1.97 ( )
Oliguria
Platelet: 96 ( )

500mL in 24h Edema

-Swelling in upper and lower

extremities
-Stretched/shiny skin
-increased abdominal size

37
 Nursing care plan 1

Assessment

Objective

 Non-pitting edema on his lower extremities

 Ascites
 Dry skin
 Weight gain (92kg)
 skin is warm to touch, shiny and tight
 Pallor
 No capillary refill
 Vital signs:
Temperature: 36 degree Celsius
Pulse rate: 89 bmp
Respiratory rate: 30 cpm
Blood pressure: 160/90 mmHg

Diagnosis

Risk for decreased cardiac output related to swelling of

abdomen and extremities.

Planning

Goal: Within 8 hours of our duty the patient will be able to

have knowledge about the risk factors and treatment plan of the
disease process.

Interventions

Independent

 Monitor vital signs

 Monitor I & O
 Restricted in high sodium foods
 Encourage client to breathe in/out during activities that
increase risk for Valsalva effect
 Discussed situation and encourage verbalization of fears
and concerns.
 Supported and encourage patient: provide care with a

38
 positive, friendly attitude.
Dependent

 Administered medications as indicated for diuretics, such

as furosemide as prescribed.
 Administered medications as indicated for antihypertensive,
such as losartan as prescribed.

Evaluation

Goal met, after 8 hours of our duty the patient had

knowledge about the risk factors and treatment plan of the
disease process.

39
 Nursing care plan 2

Assessment

Subjective

“kasakit kaayo mangihi” as verbalized by the patient

Objective
 Irritability
 Pain scale is 7 out of 10
 Decrease urine output 500ml/24hrs
 Pallor
 Non-pitting Edema at lower and upper extremities
 Vital signs:
Temperature: 36 degree Celsius
Pulse rate: 73bpm
Respiratory rate: 22 cpm
Blood pressure: 160/90 mmHg
Diagnosis

Impaired urinary elimination related to glomerular filtration

impaired secretion nitrogenous product secondary renal failure.

Planning

Goal: Within 8hrs of my duty, patient will be able to

increase level of comfort during elimination with the pain scale
of 3 out of 10.

Interventions

Independent:

 Established rapport
 Assist vital signs
 Monitor I&O
 Review for urinalysis for changes
 Determine clients pattern elimination
 Investigate pain, noting location
 Note condition of skin, mucous membrane, color of urine
 Encouraged verbalized fears and concern
 Emphasized importance of having good hygiene

40
Dependent:

 Administered analgesic medication such as Clonidine

hydrochloride as prescribed.

Evaluation

Goal met, after 8 hours of giving nursing interventions, the

patient increased level of comfort during elimination with the
pain scale of 3 out of 10.

41
 Nursing care plan 3

Assessment

Objective

 Decreased urine output: 500 ml/24hrs.

 Non-pitting Edema at lower and upper extremities
 Ascites
 Poor skin turgor , dry skin and mucous membrane
 Weight gain (from 91kg to 92kg)
 Vital signs:
Temperature: 36 degree Celsius
Pulse rate: 75 bpm
Respiratory rate: 30 cpm
Blood pressure: 160/90 mmHg

Diagnosis
Excess fluid volume related to retention of sodium as
manifested by presence of edema in upper and lower extremities.

Planning

Goal: within8 hours of nursing intervention the patient will

able to stabilized fluid volume , with balance intake and
output.

Intervention

Independent:

 Measured I & O, noting positive balance-intake in excess of

output.
 Monitored vital signs
 Measured abdominal girth to reflect accumulation of fluid
or ascites resulting from loss of plasma proteins and fluid
into peritoneal spaces.
 Provided frequent mouth care to decreased the thirst
sensation especially when fluid restricted.
 Restricted sodium and fluids, as indicated.

42
Dependent:

 Administered medications as indicated for diuretics, such

as furosemide as prescribed.

Evaluation

Goal met, after 8 hours of nursing interventions, patient

verbalized understanding of measures to prevent and lessen fluid
volume excess.

43
 Nursing care plan 4

Assessment

Subjective
“Dili pa ako kapanaw na wayay magKupot kay mura ko malipong” as
verbalized by the patient.

Objectives
• Generalized weakness
• Fatigue
• Dizziness
• Diaphoresis
• Vital signs are:
Temperature- 36.2 degrees Celsius
Pulse Rate- 123 bpm
Respiratory Rate- 28 cpm
Blood Pressure- 100/80 mmHg

Nursing Diagnosis
Activity Intolerance related to fatigue, lethargy and malaise

Planning
Goal: After 8 hours of giving nursing interventions, the patient
will be able to demonstrate increased tolerance of activity.

Interventions
Independent
 Assessed level of activity tolerance and degree of fatigue
when performing routine activities of daily living.
 Assisted with activities such as getting up from the bed,
sitting on the chair, and going to the bathroom.
 Encouraged rest when he felt very weak and when abdominal pain
and discomfort occur.

Dependent
 Supported and encourage patient: provide care with a
positive, friendly attitude.
 Encourage family/SO to verbalized feelings and participate
in care.

44
Evaluation
Goal met. After 3 hours of giving nursing interventions, the
patient demonstrated increased tolerance of activity. Patient
was able to ambulate to the bathroom and back to the bed without
any abnormal changes in vital signs and the patient stated,
“Medyo makalakaw nako paghinay-hinay na way magkupot”.

45
 Nursing care plan 5

Assessment

Subjective

“ma’am na unsa na diay ko” as verbalized by the patient

Objective

 Irritability
 Fatigue
 Non-pitting edema at upper and lower extremities
 Dry skin
 Ascites
 Weight gain from 91-92 kg
 Vital signs:
Temperature: 36 degree Celsius
Pulse rate: 75 bmp
Respiratory rate: 22cpm
Blood pressure: 150/90 mmHg
Diagnosis

Knowledge deficit related to lack of information regarding

about chronic kidney disease.

Planning

Goal: Within 4 hours of nursing intervention the patient will

be able to understand the condition process and potential
complications.

Intervention

Independent

 Discussed situation and encourage verbalization of fears

and concerns.
 Supported and encourage patient: provide care with a
positive, friendly attitude.
 Encourage family/SO to verbalized feelings and participate
in care.
 Fluid and sodium restriction

46
Evaluation

Goal met, after 4 hours of giving nursing interventions the

patient had understood the condition process and potential
complication.

47
Discharge plan
Upon discharge from the hospital, the patient and his
significant others will be given home care instructions
containing in the following:

MEDICATIONS  Continue taking the medicines

prescribed by the physician such as:
 Furosemide 40mg TID
 CaCo3 500mg BID
 Losartan 500mg OD
 NaHCO3 1 tab TID

ENVIRONMENTAL  Advised patient or SO by providing

CONSIDERATION quiet environment, and avoiding
stressful Situation.

TREATMENT  Instructed patient to follow proper

instructions medications prescribed
by the physician.
 Drink at least 8-10 glasses a day
 Eat more fruits and vegetables to
facilitate easy bowel movement.
 Minimize high Na diet
HEALTH TEACHING  Encourage personal hygiene regularly
 Minimize high Na foods
 Drink at least 8-10 glasses of water
a day.
 Encourage patient to stop alcohol
consumption.
 Encourage patient to stop smoking
 Eat more fruits and vegetables to
facilitate easy bowel movement.
 Instructed patient to minimize high
cholesterol foods.
 Instructed patient to follow proper
instructions medications prescribed
by the physician.

48
OUT-PATIENT CHECK-  Instructed patient to follow scheduled
UP check up
 Instructed patient to seek medical
attention when adverse reactions and
sign and symptom occurs.
DIET  Advised the patient’s SO to let the
patient eat nutritious food like
fruits, vegetables and green leafy
 Instructed SO to control or limit the
food of the patient which contain
sodium
SPIRITUAL  Encourage patient to be more faithful
and have trust in God
 Encourage SO to pray for the patients
early recovery

49
IVF SHEET

SUMMARY OF INTRAVENOUS FLUIDS

BOTTLE DATE AUDITIVE SOLUTION Drop Rate

VOLUME (gtts/min)

1 10/27/17 PNSS 1L 10gtts/min

2 10/28/17 PNSS 1L 10gtts/min

I and O sheet

Date/ti IVF Oral Total Urine Vomitus BM Total

me con fluid taken output outpu
Credit sumed taken t
10/27/1 900 100 300 400 200 - - 200
7
7pm
7-7am 800 100 50 150 300 - - 300
550
10/28/1 700 100 250 350 500 - - 500
7
7-7
600 100+2 100 400 500 - - 500
60
750
10/29/1 400 200 400 600 1000 - - 1000
7
7-7pm
200 200 250 650 850 - - 850
1250 1850

50
Vital signs

BLOOD PULSE RESPIRATORY TEMPERATURE SPO

TIME/DATE PRESSURE RATE RATE (°C) (%)
(mm/hg) (bpm) (cpm)
10/27/17
12nn 150/80 73 22 36 96%
4pm 140/70 81 29 36 98%
8pm 160/100 73 20 36 97%
12nn 140/90 73 20 36 97%
4am 120/90 62 21 36 97%
10/28/17
8am 150/80 63 20 36.2 98%
12nn 150/80 69 22 36 98%
4pm 160/90 63 20 36.4 97%
8pm 140/90 70 20 36.2 98%
12nn 140/90 64 20 36 98%
4am 140/90 60 20 36 97%
10/29/17
8am 140/80 88 20 36 98%
12nn 140/80 72 20 36 98%
4pm 130/80 72 22 36.4 98%
8pm 130/100 64 20 36 98%
12nn 140/90 74 20 36 99%
4am 130/80 80 20 36 99%

51
Definition of terms

Creatinine-Creatinine is a breakdown product of creatine

phosphate in muscle, and is usually produced at a fairly
constant rate by the body.

Glomerular filtration rate-Glomerular filtration rate (GFR) is a

test used to check how well the kidneys are working.
Specifically, it estimates how much blood passes through the
glomeruli each minute. Glomeruli are the tiny filters in the
kidneys that filter waste from the blood.

Protein-Proteins are large biomolecules, or macromolecules,

consisting of one or more long chains of amino acid residues.

Biopsy- A biopsy is a medical test commonly performed by a

surgeon, interventional radiologist, or an interventional
cardiologist involving extraction of sample cells or tissues for
examination to determine the presence or extent of a disease.

Anemia-Anemia is a condition that develops when your blood lacks

enough healthy red blood cells or hemoglobin. Hemoglobin is a
main part of red blood cells and binds oxygen. If you have too
few or abnormal red blood cells, or your hemoglobin is abnormal
or low, the cells in your body will not get enough oxygen.

Hyponatremia-Hyponatremia is a condition that occurs when the

level of sodium in your blood is abnormally low. Sodium is an
electrolyte, and it helps regulate the amount of water that's in
and around your cells.

Osmolarity-the concentration of a solution expressed as the

total number of solute particles per liter.

pH- pH is a measure of the hydorgen ion concentration of a

solution. Solutions with a high concentration of hydrogen ions
have a low pH and solutions with a low concentrations of H+ ions
have a high pH

Filtration-Filtration is any of various mechanical, physical or

biological operations that separate solids from fluids
(liquids or gases) by adding a medium through which only the
fluid can pass. The fluid that passes through is called
the filtrate.

52
References

https://en.wikipedia.org/wiki/Filtration

http://www.ugc.edu.hk/eng/rgc/funding_opport/general_research_fu
nd.html

https://emedicine.medscape.com/article/1948775-overview

http://www.innerbody.com/image_urinov/dige05-new.html

https://www.google.brunner+and+suddarth%27s+textbook+of+medical-
surgical+nursing+12th+edition&oq=Brunner+%26+Suddarth%27s

53
 Genogram

Mother
Father Age: 78
Age: 80 Hyperte
Hypertension nsion

Brother
Age: 68 Patient Y
Eldest Brother Sister Diabetic Sister Age: 63
Brother
Age: 65 CKD

Men

Women

Died

Alive

54