A CASE OF CHRONIC KIDNEY DISEASE SECONDARY TO

CHRONIC HYPERTENSION
Adult Phase II
Submitted by: Daryl C. Diez

INTRODUCTION
Chronic kidney disease (CKD) is defined as persistent kidney
damage accompanied by a reduction in the glomerular filtration rate (GFR)
causing build up of dangerous levels of fluid, electrolytes and wastes in the
body.
Furthermore, hypertension is one of the leading causes of CKD
due to the deleterious effects that increased BP has on kidney vasculature.
Long-term, uncontrolled, high BP leads to high intraglomerular pressure,
impairing glomerular filtration. Damage to the glomeruli lead to an increase
in protein filtration, resulting in abnormally increased amounts of protein in
the

urine

(microalbuminuria

or

proteinuria).

Microalbuminuria

is

the

presentation of small amounts of albumin in the urine and is often the first
sign of CKD. Proteinuria (protein-to-creatinine ratio 200 mg/g) develops as
CKD progresses, and is associated with a poor prognosis for kidney disease.
Hypertension has been reported to occur in 85% to 95% of
patients with CKD (stages 35). The relationship between HTN and CKD is
cyclic in nature. Uncontrolled HTN is a risk factor for developing CKD, is
associated with a more rapid progression of CKD, and is the eighth leading
cause of ESRD in the Philippines that necessitates the need for replacement
therapy, including dialysis or kidney transplantation (WHO, 2014).

Brief Description:
Statistical Data:
According to the data published by the World Health Organization
(WHO) in May 2014, deaths in the Philippines due to kidney disease reached
15,873 or 3.04% of total deaths. The age adjusted Death Rate is 25.71 per
100,000 of population ranks Philippines number 13 th in the world.
Impact of the disease:
Based on the information from the WHO data last May 2014,
CKD is the eighth leading cause of deaths in the Philippines with
hypertension as one of its main cause. It is also one of the top diseases with
the greatest burden, not only must be dealt with lifelong but consumes great
amount of money. The kidney is a vital part of the body that helps excrete
wastes and maintain homeostasis. Uncontrolled hypertension for a long
period damages the kidneys causing a lot of dysfunctions and problems
affecting different systems of the body that can greatly impact a patients
life.

Role of the nurse

Nurse practitioners (NPs)

plays a valuable role in a redesigned

process for caring of clients with chronic kidney disease by administering

medications, performing complex actions that address psychosocial and
lifestyle issues and by providing measures to prevent the development of
further complications. The nurse should also provide adequate health
teachings and facilitate referral to respective departments to meet patients
needs (e.g. regarding modification of nutritional intake, weight monitoring,
etc.) These are all done to ensure the optimum functioning of the patient.

History and Assessment:

Patient X, 44 years old; male, was admitted to Vicente Sotto Memorial
Medical Center (VSMMC) last March 10, 2016 due to complaints of dizziness and
difficulty of breathing.
Upon admission, the patients records revealed the following informant: vital
signs were HR: 94 bpm, RR: 32 cpm, temperature: 37.6 oC and BP: 180 / 100. The
patient was drowsy and incoherent upon admission. The patient has a history of
hypertension for 10 years and takes his maintenance medication, atenolol (atelol)
100mg only if he feels dizzy, but due to continuous, unrelieved symptom that was
accompanied with dyspnea, prompted him to sought consult.
The patient is a smoker consuming 1 pack of cigarettes a day and drinks
alcohol 2-3 times a week. The patient sleeps early but has trouble staying asleep
often. The patient claimed that his parents both died due to heart attack.
Upon assessment on the 10 th of March 2016, the patient feels tired or has
less energy. His vital signs were as follows HR: 84 bpm, RR: 25 cpm, temperature
37. 2 oC, BP: 150/90. The patient has O 2 therapy at 3 liters per minute, Internal
Jugular Catheter at the right neck, intravenous site adaptor on the right hand. The
patient is conscious, awake and responsive. He cannot tolerate too much activity or
movement, though, and he easily gets tired. He needs assistance in performing self
care activities like moving himself up in bed.
HEENT:
Symmetrical,
head on midline, eyes:
pupils equally reactive to light and accommodation,
no palpable lymph nodes on throat.
GASTROINTESTINAL:
is nauseous, vomits and has a poor appetite with complaints of metallic taste

 bowel movement every day or every other day

globular, symmetrical
RESPIRATORY:
uremic fetor noted
With a respiratory rate of 30 cycles per minute, shortness of breath, equal
chest expansion, crackles noted upon auscultation
Symmetric chest expansion
Resonance noted
CARDIOVASCULAR:
consistently high blood pressure ranges between 150 / 80 to 170 / 90 mmhg
jugular vein distention
GENITO-URINARY:
no pain or tenderness, urine output 10-20 ml/hour
MUSCULOSKELETAL / SENSORY:
Can ambulate in a slow pace with assistance
Dizziness and dyspnea are felt by the patient upon ambulating for more than
30 minutes
Does not use any kind of supportive ambulatory devices to aid in walking
INTEGUMENTARY:
skin is dry and dusky in appearance.
Complaints of itchiness with presence of scratch marks on some parts of his
body and head
Has swollen feet and ankles if left not elevated for an hour or so with a
pitting score of +1 (2mm) ,
no presence of skin breakdown or signs developing decubitus ulcer

Diagnostic and Laboratory Procedures:

The following tests were done:
CBC
Blood Chemistry
Chest xray
Creatinine
BUN

Lipid Profile
Fasting Blood Sugar
Blood typing
Hep panel

Result taken last March 10, 2016

Tests

Results

Normal Values

Total Cholesterol

192.05mg/dL

Up to 200 mg/ dL

Triglycerides

253.47mg/dL

Up to 150 mg/dL

HDL cholesterol

37.66 mg/dL

> 35 mg/dL

VLDL cholesterol

50.69mg/dL

< 40 mg/dL

LDL cholesterol

135.05 mg/dL

< 150 mg/dL

FBS

104.34 mg/dL

70 105 mg/dL

Serum Creatinine
Blood Urea Nitrogen

14.24mg/dL
65.22 mg/dL

Sodium

155mEq/L
H
4.8mEq/ L
1.08
10.42mg/dl
34g/l

Potassium
Ionized Calcium
Phosphorus
Albumin

Hepatitis B antigen
Hepatitis C antigen

0.5- 1.3mg / dL
7-20 mg / dL

135-145 mEq/L
H

3.5-4.5 mEq/L
1.13-1.32 mmol/L
H 2.6-4.5 mg/ dl
L 35-45 g/l

NEGATIVE
NEGATIVE

Parameter

Result and unit

Reference Range

WBC

9.72 x 10^9/L

5.00 10.00

Neutrophils %

79.1%

Lymphocytes %

11.2%

Monocytes %

8.4%

H 1.0 6.0

Eosinophils %

1.1%

0.0 3.0

Basophils %

0.2%

0.0 1.0

Neutrophils #

7.69 x 10 ^9/L

H 2.00 7.00

Lymphocytes#

1.09 x 10 ^9/L

0.80 4.00

Monocytes#

0,82 x 10 ^9/L

0.12 1.20

Eosinophils#

0.10 x 10 ^9/L

0.02 0.05

Basophils#

0,02 x 10^9/L

0.00 0.10

RBC

3.05 x 10^12/L

HGB

90 g/L

L 140 -180

HCT

22.0 %

Blood type

50.0-70.0
20.0 40.0

4.00 5.00

42.0 54.0

O Positive

Chest X ray revealed increased hydrostatic pulmonary capillary pressure indicative of fluid buildup
(pulmonary congestion). Correlate with other diagnostics

NURSING CARE PLAN

Renal disorder impairs glomerular filtration that resulted to fluid overload. With
fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into
the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume
overloads the lymph system and stays in the interstitial spaces leading the patient to have
edema, weight gain, pulmonary congestion and HPN at the same time due to decrease GFR,
nephron hypertrophied leading to decrease ability of the kidney to concentrate urine and
impaired excretion of fluid thus leading to oliguria/anuria.
Nursing Diagnosis: Excess fluid volume related to compromised regulatory
mechanisms of the body as evidenced by pulmonary congestion on cxr, increased
blood pressure, tissue edema of the lower extremities, weight gain and decreased
urine output
Goal: The patient will be able to display appropriate Maintenance of ideal body
weight without excess fluid as manifested by near normal; stable weight, vital
signs within patients normal range; and absence of edema
Nursing Interventions
INDEPENDENT
1. Assess fluid status:
a. Daily weight
b. Intake and output
balance

Rationale
1. Assessment provides
baseline and ongoing
database for
monitoring changes
and evaluating
interventions.

d. Distention of neck
veins

2. Fluid restriction will be

determined on basis
of weight, urine
output, and response
to therapy.

e. Blood pressure,
pulse rate, and
rhythm

3. Unrecognized sources of
excess fluids may be
identified.

f. Respiratory rate
and effort

4. Understanding promotes
patient and family
cooperation with fluid
restriction.

c. Skin turgor and

presence of edema

2. Limit fluid intake to

prescribed volume.
3. Identify potential sources
of fluid:
a. Medications and
fluids used to take
or administer
medications: oral
and intravenous
b. Foods

5. Increasing patient
comfort promotes
compliance with
dietary restrictions.
6. Oral hygiene minimizes
dryness of oral
mucous membranes.

Expected Outcomes

Demonstrates no
rapid weight
changes

Maintains dietary
and fluid
restrictions

Exhibits normal
skin turgor
without edema

Exhibits normal
vital signs

Exhibits no neck
vein distention

Reports no
difficulty
breathing or
shortness of
breath

Performs oral
hygiene
frequently

Reports
decreased thirst

Reports
decreased
dryness of oral

4. Explain to patient and

family rationale for fluid
restriction.

mucous
membranes.

5. Assist patient to cope

with the discomforts
resulting from fluid
restriction.
6. Provide or encourage
frequent oral hygiene.
DEPENDENT:
1. Administer medication as
indicated: Diuretics:
furosemide (Lasix),
bumetanide (Bumex),
torsemide (Demadex)
2. Antihypertensives:
clonidine (Catapres),
methyldopa (Aldomet),
prazosin (Minipress).
3. Monitor laboratoties
(ECG, electrolytes etc.)
4. Prepare for dialysis as
indicated:
hemodialysis,peritoneal
dialysis, or continuous
renal replacement
therapy (CRRT).

1. flush the tubular lumen

of debris, reduce
hyperkalemia, and
promote adequate urine
volume.
2. May be given to treat
hypertension by
counteracting effects of
decreased renal blood
flow and/or circulating
volume overload.
3. to note effectiveness of
treatment and to
monitor for possible side
effects of medication
given.
4. Done to correct volume
overload, electrolyte
and acid-base
imbalances, and to
remove toxins. The type
of dialysis chosen for
ARF depends on the
degree of hemodynamic
compromise and
patients ability to
withstand the
procedure.

Due restricted foods and prescribed dietary regimen, an individual experiencing

renal problem cannot maintain ideal body weight and sufficient nutrition. At the
same time patients may experience anemia due to decrease erythropoietic factor
that cause decrease in production of RBC causing anemia and fatigue
Nursing Diagnosis: Altered nutrition: risk for less than body requirements related
to protein catabolism; dietary restrictions to reduce nitrogenous waste products
as evidenced by anorexia, nausea, vomiting, dietary restrictions, and altered oral
mucous membranes
Goal: Maintenance of adequate nutritional intake

1. Assess nutritional status:

1.

a. Weight changes
b. Laboratory values
(serum electrolyte,
BUN, creatinine,
protein, transferrin,
and iron levels)
2. Assess patient's nutritional
dietary patterns:
a. Diet history
b. Food preferences
c. Calorie counts
3. Assess for factors
contributing to altered
nutritional intake:

Past and present

dietary patterns are
considered in planning
meals.
3.
Information about
other factors that may
be altered or eliminated
to promote adequate
dietary intake is
provided.
4.

Increased dietary
intake is encouraged.

5.

Complete proteins
are provided for positive
nitrogen balance needed
for growth and healing.

6.

c. Depression
d. Lack of understanding
of dietary restrictions
e. Stomatitis
4. Provide patient's food
preferences within dietary
restrictions.
5. Promote intake of high
biologic value protein foods:
eggs, dairy products, meats.

7.

8.

6. Encourage high-calorie, lowprotein, low-sodium, and

low-potassium snacks
between meals.
7. Alter schedule of medications
so that they are not given
immediately before meals.

Consumes
protein of high
biologic value

Chooses foods
within dietary
restrictions that
are appealing

Consumes highcalorie foods

within dietary
restrictions

Explains in own
words rationale
for dietary
restrictions and
relationship to
urea and
creatinine levels

Takes
medications on
schedule that
does not produce
anorexia or
feeling of
fullness

Consults written
lists of
acceptable foods

Reports
increased
appetite at
meals

Exhibits no rapid
increases or
decreases in
weight

Demonstrates
normal skin
turgor without
edema; wound
healing and

2.

a. Anorexia, nausea, or
vomiting
b. Diet unpalatable to
patient

Baseline data allow

for monitoring of
changes and evaluating
effectiveness of
interventions.

9.

Reduces source of
restricted foods and
proteins and provides
calories for energy,
sparing protein for
tissue growth and
healing.
Ingestion of
medications just before
meals may produce
anorexia and feeling of
fullness.
Promotes patient
understanding of
relationships between
diet and urea and
creatinine levels to renal
disease.
Lists provide a
positive approach to
dietary restrictions and
a reference for patient

8. Explain rationale for dietary

restrictions and relationship
to kidney disease and
increased urea and
creatinine levels.
9. Provide written lists of foods
allowed and suggestions for
improving their taste without
use of sodium or potassium.
10.
11.
12.

Provide pleasant
surroundings at meal-times.
Weigh patient daily.
Assess for evidence of
inadequate protein intake:
a. Edema formation
b. Delayed wound
healing
c. Decreased serum
albumin levels

COLLABORATIVE
1. Consult with dietitian
support team

DEPENDENT
1. Administer medications
as indicated. Antiemetics:
prochlorperazine
(Compazine),
trimethobenzamide
(Tigan

and family to use when

at home.
10.

Unpleasant factors
that contribute to
patient's anorexia are
eliminated.

11.

Allows monitoring of
fluid and nutritional
status.

12.

Inadequate protein
intake can lead to
decreased albumin and
other proteins, edema
formation, and delay in
wound healing.

1. Determines individual
calorie and nutrient
needs within the
restrictions, and
identifies most effective
route and product (oral
supplements, enteral or
parenteral nutrition).
1. Given to relieve N/V and
may enhance oral intake.

acceptable
plasma albumin
levels

Discharge Summary:
The disease has long term effects to the body that can affect the
patient holistically. Lifestyle habits, dietary and activity are some of the changes
that must be thought. The following are some of the activities that must be
educated to the patient:
You will need to return for tests to monitor your kidney function. You may also
be referred to a kidney specialist.
Follow your healthcare provider's directions on how to manage high blood
pressure. These conditions can make CKD worse that may resut to death. Talk
to your healthcare provider before you take over-the-counter medicine.
Weigh yourself daily: Ask your healthcare provider what your weight should be.
Ask how much liquid you should drink each day. CKD may cause you to gain or
lose weight rapidly. Weigh yourself every day. Write down your weight, how
much liquid you drink or eat, and how much you urinate each day. Contact your
healthcare provider if your weight is higher or lower than it should be.
Exercise 30 to 60 minutes a day, 4 to 7 times a week, or as directed. Ask about
the best exercise plan for you. Regular exercise can help you manage CKD and
high blood pressure.
Follow your healthcare provider's advice about what to eat and drink. He may
tell you to eat food low in sodium (salt), potassium, phosphorus, or protein. You
may need to see a dietitian if you need help planning meals. Ask how much
liquid to drink each day and which liquids are best for you.
Do not smoke. Nicotine and other chemicals in cigarettes and cigars can cause
lung and kidney damage. Ask your healthcare provider for information if you
currently smoke and need help to quit. E-cigarettes or smokeless tobacco still
contain nicotine. Talk to your healthcare provider before you use these
products.