CHRONIC KIDNEY

DISEASE

APOLINARIO, CARREN
GALVEZ, BENAND CHARLOTTE B.
NAGUAIT, ALJON
VIANZON, REYNALDO JR. M

INTRODUCTION
A. A case patient with Chronic Kidney Disease was made available in the
medical ward at ICMC hospital. The medical records and progress notes
were obtained and an interview with the patient was conducted.
The medical records were then analyzed and data from the interview were
correlated to get a better understanding on the patients disease condition.
A nursing care plan was formulated providing short term and long term
goals to help delay of the progression of the disease and to prevent further
complications to improve the patients health status.
B. Disease Condition
Chronic Kidney Disease is a progressive and irreversible damage of the
functioning unit of the kidneys, the nephrons. It is a progressive loss in
renal function over a period of months or years. The symptoms of
worsening kidney function are non-specific 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 complication, such as cardiovascular disease, anemia or
pericarditis. It is differentiated from acute kidney disease in that the
reduction in kidney function must be present for over 3 months. It is
identified by a blood test for creatinine. Higher levels of creatinine indicate
a lower glomerular filtration rate and as a result a decreased capability of
the kidneys to excrete waste products.
As renal function deteriorates, nitrogen containing waste products
accumulate in the blood and the uremic syndrome develops. Uremic
syndrome is the cluster of clinical findings associated with the build-up of
nitrogen containing in the blood, which may include fatigue diminished
mental alertness, agitation, muscle twitches, cramps, anorexia, nausea,

vomiting, inflammation of the membranes of the mouth, itchy skin, skin

hemorrhages, gastritis, GI bleeding and diarrhea.
C. Classification / Types
Renal failure can be acute or chronic. In acute renal failure, the nephrons
suddenly lose function and are unable to maintain homeostasis. On the
other hand, chronic renal failure, the GFR drops suddenly and sharply. The
GFR deteriorates and renal function is irreversibly altered.
Chronic renal disease results from irreversible loss of large numbers of
functioning nephrons. It can be categorized into five stages. The first stage
is when the kidney is damaged with GFR>90 mL/min. Second stage is when
GFR reaches down to 60 to 89 mL/min. In the third stage, GFR falls to 30-59
mL/min. In the fourth stage, the kidney damage is severe and the GFR is
already too low reaching 15-29 mL/min. Finally in the 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.

I.

DEMOGRAPHIC DATA

Name:

RUBEN V. MEDINA

Date of Birth:

JANUARY 31, 1947

Age:

67 Y/O

Gender:

MALE

Address:

69 PARAISO ST. ORANI, BATAAN

Civil Status:

MARRIED

Nationality:

FILIPINO

Religion:

ROMAN CATHOLIC

Occupation:

N/A

Date Admitted: NOVEMBER 22, 2014

Physician:

Dr. Diwa

Chief Complaint: Difficulty of Breathing, cough, fever

II. HISTORY OF PRESENT ILLNESS

One day PTA, November 21st , when patient had failed to submit
himself for regular hemodialysis session (three days post last
hemodialysis) because of financial constraints, he experienced an
increased severity of difficulty in breathing accompanied by nonproductive cough, chills and fever. Prompt hospital-ER consult, hence
admission.

III. PAST HEALTH HISTORY

Medical History:

DM 2, HYPERTENSION, CKD

Surgical History:

NONE

Accidents:

NONE

Medications:

MULTIVITAMINS (CENTRUM)

Prescribed Medications:

INSULIN

Childhood Illness & Immunization:

CHICKENPOX @ 7 Y/O,
NO IMMUNIZATION VACCINE/S
Allergies:

NO KNOWN FOOD / DRUG ALLERGY

On November 1, 2007, he was brought to the ER of San Juan de Dios

hospital due to difficulty in breathing.
Diagnosis was CKD stage five thence, he had undergone immediate
hemodialysis using a catheter via right subclavian vein approach.
He was admitted and stayed there for two weeks.

December 4, 2007, an arteriovenous fistula was made on his left wrist

and he has been undergoing hemodialysis twice a week from then on,
Wednesdays and Saturdays.

FAMILY HISTORY OF ILLNESS

Has no familial history of hypertension, cancer, tuberculosis and
asthma.
His father died at the age of 48 due to chronic kidney disease stage III.
His mother died at the age of 62 due to complications caused by DM.
Including the heart, kidney and liver.

PSYCHOSOCIAL HISTORY
Patient is a 67-years old, retired OFW from K.S.A since 2007. Smoker,
regular alcoholic beverage drinker, consuming 3-4 bottles at least four
times a week.
With preference on taking in soda (four 8 ounce-bottles per day) and
consuming only at least 4 half glasses of water per day.
He is third in a brood of four in the family.

ACTIVITIES OF DAILY LIVING

Activity

Fluids and
nutrition

Before
hospitalization
Pre hemodialysis
Drinks alcoholic
beverages at 3 to 4
bottles four times
a month. He eats 2
full meals per day
(skips either
breakfast or
dinner). For
breakfast he
usually haves
bread and water.
Lunch usually
fast food
consisting of deep
fried dishes
Snacks junk food
(chips) and soda,
approximately 4 8ounce bottles per
day
Drinks 4 halfglasses of water
daily
Dinner - often
skipped

During
hospitalization

Analysis

The patients
fluids are partly
supplied
intravenously:
D5NSS 1L x KVO
running at
10cc/hr. His
diet was
maintained to
low salt, low
protein, low
potassium. He
eats 3 times per
day but in small
amounts
because of poor
appetite. The
patient drinks a
maximum of
four glasses of
water a day.

IV fluids are
given for
hydration. He
eats twice a
day. Pre
hemodialysis,
the patient
frequently skips
one meal due to
poor of
appetite. During
hospitalization
the patient had
a diet
restriction (low
salt, low protein
and low
potassium). This
was the diet
ordered by the
doctor since
high levels of
these three
worsen the
clients
condition.

Activity

Elimination

Before
hospitalization
Pre hemodialysis
The patient usually
voids 4 6 times a
day and defecates
regularly at least
once a day.
During hemodialysis
Voids two to four
times per day and
defecates regularly.

During
hospitalization
The patient
voids two to
four times a
day,
approximately
240cc, and
defecates
regularly.

Analysis
Less urine
output due to
inability of the
kidneys to
concentrate
urine because
of the disease
process.

Rest and
sleep

The patient has an The

patient
average of 5 hours now has an
of continuous sleep. irregular
pattern of sleep

Interrupted
sleep during
hospitalization
because of
environmental
factors and
hospital
procedures.

Exercise

The patient prefers

walking during free
time

Exercises
through short
sitting and
standing ups.

Easy fatigability
because of lack
of oxygenation

Takes a full bath

once every 2 days
and brushes once.

Does partial
baths daily

Because fatigue
is a likely
problem.

Hygiene

PHYSICAL ASSESSMENT
ASSESSMENT TECHNIQUE NORMAL ACTUAL
USED
FINDINGS FINDINGS
VITAL SIGNS:
T: 36.8
PR: 76
RR: 33
BP: 130/90
WT: 52kg
HT: 5 feet
and 7 inches

SIGNIFICANCE

ASSESSMENT

A) GENERAL
SURVEY
Body build, height
and weight in
relation to clients
age
Clients posture
and gait, standing,
sitting, and
walking
Overall hygiene
and grooming
Body and breath
odor

TECHNIQUE
USED
Inspection
Inspection
Inspection
Inspection

NORMAL
FINDINGS

ACTUAL
FINDINGS

SIGNIFICANCE

Proportionate Underweight
(BMI of
Relaxed,
16.12)
erect
posture,
(Normal
coordinated
18-20)
movement

Due to protein
energy
malnutrition
and effects of
wasting

Neat and
clean

Normal

No
body/minor
body odor;
no breath
odor

Relaxed,
erect
posture,
coordinated
movement
Neat and
clean
No
body/minor
body odor;
no breath
odor

Normal

Normal

ASSESSMENT TECHNIQUE NORMAL

USED
FINDINGS
Obvious signs of Inspection
health or illness
Inspection
Clients attitude
Inspection
Clients mood;
Inspection
assess the
Appropriateness
of the clients
response
Quality,
quantity and
organization of
speech

ASSESSMENT TECHNIQUE

ACTUAL
FINDINGS

SIGNIFICANCE

Healthy
Pallor,
appearance yellowish
extremities,
Cooperative
weakness,
Appropriate obvious
to situation illness

Inadequate
circulating blood
and subsequent
reduction in
tissue
oxygenation and
decreased
metabolic energy
production and
dietary
restrictions

Understand Cooperative
able; exhibit
Appropriate
thought
to situation
association
Understanda
ble; exhibit
thought
association

Normal
Normal
Normal

NORMAL

ACTUAL

SIGNIFICANCE

USED
Relevance and Inspection
organization of
thoughts
B) SKIN
Skin color

Inspection

Uniformity of
skin color

Inspection

Assess edema

Inspection

Observe and
palpate skin
moisture

Inspection

Skin
temperature

Palpation

FINDINGS

FINDINGS

Logical
sequence

Logical
sequence

Varies to
medium
dark brown

Dark Brown

Normal

Impaired
excretion of
urinary
Areas that
pigments as
have
well as the
Yellowish in presence of
color
anemia due to
Generally
lack of
uniform
erythropoietin
except in
With edema being produced
palm & sole @ R hand , IV Due to water
site (edema
retention and
scale 1+,
increase
No edema
barely
permeability of
detectable)
membrane that
results from
Moisture in
Severe
shifting of fluids
skin folds
dryness
Decrease in
and the
of the skin
hydration that
axillae
affects
circulation and
tissue integrity
at the cellular
Uniform;
level
within
Uniform;
Normal
normal range within
normal range

ASSESSMENT TECHNIQUE NORMAL

USED
FINDINGS

ACTUAL
FINDINGS

SIGNIFICANCE

C)

Evenly
distributed

Evenly
distributed

Normal

Thick hair

Thick hair

Silky and
resilient
hair

Silky and
resilient
hair

HAIR

Evenness of
growth over
the scalp
Thickness or
thinness of
hair

Inspection
Inspection
Inspection
Inspection

Normal
Normal
Normal

No
No
infection or infection or
infestation infestation

Texture &
oiliness
Presence of
infections or
infestations
D)

NAILS Inspection

Fingernail
plate shape
Texture
Nail bed
color
Tissues
surrounding
nails
Allens test

Inspection
Inspection
Inspection
inspection

Convex
curvature

Convex
curvature

Normal

Smooth

Smooth

Highly
vascular,
pink

Pallor

Circulatory
impairment
due to
decreased
erythropoietin

Intact
epidermis
Prompt
return

Intact
epidermis
Weak
return
(approx
w/in 4 sec)

Normal

Normal
Circulatory
impairment

ASSESSMENT TECHNIQUE NORMAL ACTUAL

USED
FINDINGS FINDINGS
E)

HEAD

Size, shape
and symmetry

Inspection
Palpation
Inspection

Presence of
nodules,
masses or
depressions in
the skull

Palpation

Facial features

Inspection

Inspect the
eyes for
edema and
hollowness

Inspection

Symmetry of
facial
movements

Inspection

Rounded,
smooth
skull
contour

Rounded,
smooth
skull
contour

SIGNIFICANCE

normal

Absence of Absence of normal

nodules
nodules
and masses and masses
Normal
Symmetric/ Symmetric/
Due to fluid
slightly
slightly
asymmetric asymmetric retention, increases
permeability of
No edema Periorbital membrane that
and
edema at
results from shifting
hollowness OU
of fluids
noted
Symmetric Normal
Symmetric facial
facial
movements
movements

ASSESSMENT TECHNIQUE
USED
F)

EYES

Inspection

Inspect for
eyebrows for
hair
distribution
and alignment
and skin
quality and
movement

Palpebral
conjunctiva

ACTUAL
FINDINGS

Hair evenly
distributed;
intact skin

Hair evenly
distributed;
intact skin

Skin intact;
no discharge
noted; no
discoloration

Inspect eyelids Inspection

for surface
characteristics
(skin quality &
texture)
Bulbar
conjunctiva

NORMAL
FINDINGS

Inspection

Inspection

Transparent
capillaries;
sclera
appears
white
shiny,
smooth and
pink or red
in color

SIGNIFICANCE
Normal
Normal

Due to retention of
Skin intact;
nitrogenous wastes
no discharge
which causes
noted; no
secondary
discoloration
hemolysis of RBCs
thus increasing the
blood levels of
Yellowish in
bilirubin
color (icteric
sclera)
due to decrease
erythropoietin
Extremely
production;
pale
Inadequate
circulating blood
subsequent
reduction in tissue
oxygenation.

ASSESSMENT TECHNIQUE
USED

NORMAL
FINDINGS

ACTUAL
FINDINGS

SIGNIFICANCE

Pupils color,
shape and
symmetry of size

Black in color,
equal size,
normally 3 7mm in
diameter,
round smooth

Black in color,
equal size,
normally 3 7mm in
diameter,
round smooth

Normal

Illuminated
pupil constricts
(direct)

Illuminated
pupil constricts
(direct)

Pupils direct and

consensual and
reaction to light
Reaction to
accommodation

Inspection

Inspection

inspection

Normal

Normal

Nonilluminated Nonilluminated
pupil constricts pupil constricts
(consensual)
(consensual)
Pupils constrict Pupils constrict
when looking
when looking
at near
at near
objects; dilate objects; dilate
when looking
when looking
at far objects;
at far objects;
pupils
pupils
converge when converge when
near objects is near objects is
moved toward moved toward
nose
nose
G)

EARS

Auricles (color,
symmetry, and
position)
Clients response
to normal voice
tones

Inspection

Inspection

Color same as
facial skin;
symmetrical;
aligned with
outer canthus
of eye

Grayish-bronze
color (sallow);
symmetrical;
aligned with
outer canthus
of eye

Normal voice
tone audible

normal voice
tone audible

Impaired excretion of
urinary pigments
(urochromes) as well
as the presence of
anemia due to lack of
erythropoietin being
produced
normal

ASSESSMENT

H)

TECHNIQUE
USED

NORMAL
FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

NOSE

Deviations in
shape, size,
color and
presence of
flaring/disch
arge from
nares

Inspection

Presence of
tenderness,
masses and
displacemen
ts of bone
and cartilage

Palpation

Patency of
both nasal
cavities

Symmetric,
straight, no
discharge/flaring
Uniform color
Absence of
lesion/tenderness

Symmetric,
straight, no
discharge/flaring;
grayish bronze
color (sallow)
Absence of

lesion/tenderness
Air moves freely as
the client breathes Air moves freely as
the client breathes

Impaired excretion of
urinary pigments
(urochromes) as well
as the presence of
anemia due to lack of
erythropoietin being
produced

Normal

Normal

Inspection

I)
MOUTH
Outer and
inner lips for
symmetry of
contour,
color and
texture
Condition of
teeth
Position of
tongue,
presence of
lesion
Sense of

Inspection

Inspection

Inspection

inspection

Uniform pink in
color; moist,
smooth texture

Teeth is smooth,
white in color
Central position;
no lesion
Normal taste

Pallor, fissures and

dryness

Due to excessive
dryness, decrease
hydration and
impaired circulation

Normal
Teeth is smooth,
white in color
Central position; no
lesion
Presence of
metallic/salty taste

Normal

Breakdown of urea to
ammonia in saliva

taste

J)

as stated by the
patient

NECK

Neck
muscles for
abnormal
swelling or
masses
Enlargement
of lymph
nodes

Palpation

Palpation

Muscle equal in
size; head
centered

Lymph node not

palpable

Muscle equal in
size; head centered

Normal

Lymph node not

palpable
Normal

ASSESSMENT

TECHNIQUE
USED

K)
THORAX
AND LUNGS
Breathing
patterns
Adventitious
breath sounds

L)

HEART

Abnormal
pulsation, lifts
and heaves
Distention of
jugular veins
Peripheral
perfusion

M)

Auscultation
Auscultation

Inspection
Palpation
Palpation

Inspection
Palpation

Bladder
retention

Inspection
Palpation
Palpation

ACTUAL
FINDINGS

Full and
With slight
symmetric chest
evidence of
expansion, quiet,
substernal
rhythmic and
retraction during
effortless
respiration
breathing
Absence of
adventitious
sounds

ABDOMEN

Skin integrity,
color, contour
and symmetry

NORMAL
FINDINGS

Presence of rales

No pulsation, lift
and heaves;
symmetric pulse
volumes

No pulsation, lift
and heaves;
symmetric pulse
volumes

Jugular vein is
not visible

Jugular vein is
not visible

Skin color pink,

temperature not
excessively
warm or cold

Skin color is
grayish bronze
(sallow),
temperature
within normal
range

Unblemished
skin, uniform in
color, no
evidence of
enlargement of
liver or spleen,
flat rounded or
scaphoid

Unblemished
skin, grayish
bronze in color
(sallow), no
evidence of
enlargement of
liver or spleen,
has rounded
abdomen

Bladder not
palpable

Bladder is nonpalpable at time

of assessment

SIGNIFICANCE

Due to
compression of
lungs caused by
accumulation of
fluids
Increased fluid
volume

Normal
Normal
Deposition of
pigmented
metabolites or
urochromes or
urea itself

Deposition of
pigmented
metabolites or
urochromes or
urea itself
normal

ASSESSMENT

TECHNIQUE
USED

NORMAL
FINDINGS

ACTUAL
FINDINGS

A) EXTREMITIES

Inspection

Equal in size,
no
deformities,
no tenderness,
swelling and
edema

R hand, edema
noted , wheal
and punctured
wound (1+
barely
detectable)

Upper

Palpation

Lower

Inspection
Palpation

SIGNIFICANCE

Due to water
retention and
increase
permeability of
membrane that
Equal in size,
L hand, with
results from
no
arteriovenous shifting of fluids
deformities,
fistula @ wrist
from
no tenderness, with palpable
intravascular
swelling and strong thrill and and interstitial
edema
bruits present
compartments
No tenderness,
swelling,
edema
formation; no
lesions; equal
in size. Dry skin.

Decrease in
hydration that
affects
circulation and
tissue integrity
at the cellular
level

Anatomy and Physiology

The Kidneys
Located at the right and left lumbar area
Responsible for the regulation of acid-base and electrolyte balance
through excretion of nitrogenous waste.

Functions of the Urinary System

Excretion
Blood volume control
Ion concentration regulation
pH regulation
Red blood cell concentration
Vitamin D synthesis

Pathophysiology
Chronic Glomerulonephritis Repeated inflammation
Ischaemia,
Nephron loss, Shrinkage of Kidney Renal Blood Flow Renal Reserve
Damage to Nephrons 50% damage More than 75% damage Renal
Insufficiency As nephrons are destroyed, the remaining nephrons undergo
changes to compensate for those that are lost Remaining nephrons must filter
more solute particles from the blood Hypertrophy of remaining nephrons
Nephrons cannot tolerate the work Further damage of nephrons 80-90%
damage Renal Failure Impaired kidney function & Uremia > 90%
kidney damage End Stage Renal Dse. (ESRD)
Renal Failure Retention of wastes Cells become resistant to insulin Glucosuria

Dialysis
Remove fluid and uremic waste products
Methods of therapy
Hemodialysis

Dialysis by need
Acute dialysis
Increased serum potassium level
Fluid overload
Impending pulmonary edema
Increasing acidosis
Medications and toxins in the blood
Chronic dialysis
CRF (ESRD)
Presence of uremic signs and symptoms
Hyperkalemia
Fluid restriction

Hemodialysis
A continuous renal replacement therapy
Treatment usually occurs three times a week for at least
three to four hours
For survival in control of uremic symptoms

Principles of Hemodialysis
Diffusion
Osmosis
ultrafiltration

Arteriovenous Fistula

A permanent access by joining an artery into a vein, either

side to side or end to side
Needles are inserted into the vessel to obtain blood flow
adequate to pass through the dialyzer

Dialyzer

Complications of Hemodialysis

GIT problems
Major sleep problems
Hypotension during treatment
Muscle cramps
Dysrhythmias
Air embolism
Chest pain
Dialysis disequilibrium

Laboratory and Diagnostic

Examination
Chest X-Ray (Portable)
Date: 27 November 2014

Result
Findings:
Chest AP view shows congestive changes in both lungs.
Heart is magnified.

Analysis:
Congestion is due to pulmonary edema. Retention of Na
and H2O.

Arterial Blood Gas Reports

Date: 27 November 2014

Time: 3:37 PM

(/)Nasal Cannula/ Oxygen Mask

Result:

Normal Range

Actual Value

pH

7.35-7.45

7.33

PaCO2

35-45mmHg

24mmHg

PaO2

80-100mmHg

52

HCO3

22-26mmEq/L

13

Base Excess

0+ / -2

-11

O2

97-100%

85%

Complete Blood Count

Diagnostic/Labo Normal
ratory
Values

Result Analysis and

Interpretation

HEMATOLOGY:

5.0-10.0 /
mm3

21.70
H

Result was above

normal. This shows
that there is
presence of
infection.

Erythrocytes

4.2-5.4 /
mm3

3.24
L

Result was below

normal. This
indicates alteration
in erythropoietin
production
secondary to renal
malfunction.

Hemoglobin

11.0-15.0 /
mm3

9.5 L Result was below

normal. This shows
the decrease in the
oxygen carrying
capacity of the blood
secondary low
hematocrit..

Hematocrit

37.0-47.0 /
mm3

28 L Result was below

normal, thus

Leukocytes

showing anemia
related to
insufficient RBC
production.
Thrombocytes

150-450 /
mm3

442

Normal.

Neutrophils

50-70 / mm3 89.200 Result shows

H
increased in normal
level, indicating
bacterial infection.

Diagnostic/Labora Normal Values Result

tory

Analysis and
Interpretation

Lymphocytes

20.0-40.0 /
mm3

55.00 H

Result is above the

normal range,
indicating bacterial
infection.

Monocytes

0.0-7.0 / mm3

3.800

Normal.

Eosinophils

0.00-5.00 /
mm3

1.200

Normal.

Basophils

0.000-1.000 /
mm3

0.300

Normal.

Chemistry
Normal value

Result

Analysis

7-20

111 mg/dl
H

Result was
above the
normal range
indicating
renal
malfunction.

Creatinine

0.52-1.25

16.83mg/dl
H

Result was
above normal
thus showing
inability of
the kidney to
excrete
nitrogenous
waste.

Sodium

137-145

150 mmol/l
H

Result shows
an increased
in normal
level of
sodium, thus
suggesting
renal
dysfunction.

CHEMISTRY:
Urea
Nitrogen

Normal value

Result

Analysis

Potassium

3.5-5.1

6.2 mmol/l
H

Result shows
an increased
in normal
level of
potassium,
thus
suggesting
renal
dysfunction.

Phosphorus

2.5-4.5

12.9mg/dl
H

Result shows
an increased
in normal
level of
phosphorus,
thus
suggesting
renal
dysfunction.

Calcium

1.12-1.32

1.08mmol/l
H

Result shows
an increased
in normal
level of
calcium, thus

indicating
renal
dysfunction.

Urinalysis

Result

Analysis

Physical
Color

Light
Yellow

Normal

Reaction

8.5 ph

Substance in the body that

contribute to the acidity level
of the blood remains, and this
inability to concentrate urine
may be a cause of renal
dysfunction.

Transparency Turbid

It contains RBCs, WBCs and pus

which indicates
malfunction of the kidneys to
reabsorb and filters.

Specific
Gravity

Normal

1.010

Albumin

Result

Analysis

+++

Increased albumin excretion is an

indicative of increased
permeability of the filters of
kidney (glumerolus), and may
be caused by disease (diabetes,
hypertension, lupus, infections,
nephritis).

Sugar

Trace

High level of glucose and other

sugar in the urine can be caused by
advanced kidney disease, impaired
tubular reabsorption.

Pus cells

4-6/hpf

RBC

0-2/hpf

Epithelial
cells

Many

There is presence of bacterial

infection as evidenced by presence
of bacteria, pus cells and RBCs.

Bacteria

Few

GENERIC/
TRADE
NAME

DOSAGE
CLASIFICATION
FREQUENCY

INDICATION

CONTRAIN
DICATION

SI