CITY OF MANILA

UNIVERSIDAD DE MANILA

(Formerly City College of Manila)

Mehan Gardens, Manila

College of Nursing

Case Study of Chronic Renal Failure

(Chronic Kidney Disease)

In Partial Fulfillment for the requirements on related learning experience

Submitted by:

Pacol, Hyazinth Mae D.

Pidal , John Nikko

Romero , Ivy Kristine

Salvador, Richelle Rose N.

Santos , Analyn

Silverio , Edison

Soriano, Marielle S.

Tabora , Liezel

Usi, Ada Clara R.

Ventura, Cyril G.

NR31-Group 4
Table of contents

Acknowledgement
Chapter I Introduction
1. Background of study
2. Significance of the Study
3. Objective of the case study
4. Scope and Limitation

Chapter II - Nursing Summary

A. Nursing health history
a. Biographical Data
b. Admission Data
c. Chief Complaint
d. History of Present Illness
e. Past Medical History
f. Family History
g. Gordons Functional Health Pattern
B. Physical Assessment
C. Laboratory and Diagnostic Exam
D. Course in the Ward
Chapter III Clinical Discussion and description of disease
A. Definition and description of disease
B. Anatomy and Physiology / Pathophysiology / Schematic Diagram of disease
C. Drug Study
D. Medical- Surgical management
Chapter IV
A. List of prioritization
B. Nursing Care Plan
C. Discharge Planning
Acknowledgement

The advocates of this case study would like to extend their warmest appreciation
to all the people who made the success for the making of this case study.

First of all , to the Almighty God, for his Everlasting love and blessings ; for giving
us enough knowledge and power to finish this work. Praise and all glory to you. Our
God.

To our Clinical Instructors for their priceless time, knowledge and effort rendered
to us.

To our Dear families and friends, for their endless support and understanding ; for
always being there to guide us and care for us after the long days of duties ; for being
our inspiration to finish this seemingly impossible task.

To the patient and their families for challenging us to do more and for giving us
strength to give our best in rendering care and giving them enough knowledge in our
health teachings.

To the group, we would like to recognize each other for our own efforts in order to
complete this case study; for making together through hardships and for simply being
there.

Lastly, to each and everyone who helped realize their job into completion, no
matter how minimal, the gratitude and pleasure for the achievement of this task is ours
to share.
Chapter I

I. Introduction

Chronic renal failure or ERSD, is a progressive, irreversible deterioration in renal

function in which the bodys ability to maintain metabolic and fluid and electrolyte
balance fails resulting in uremia or azotemia. The term "renal" refers to the kidney, so
another name for kidney failure is "renal failure." Mild kidney disease is often called
renal insufficiency.

The incidence of ESRD has increased by almost 8% per year for the past 5
years. 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.

Environmental and occupational agents that have been implicated in chronic

renal failure include lead, cadmium, mercury and chromium. Dialysis or kidney
transplantation eventually becomes necessary for patients survival. Dialysis is an
effective means of correcting metabolic toxicities at any age.
Background of the study

Chronic renal failure or ERSD, is a progressive, irreversible deterioration in renal

function in which the bodys ability to maintain metabolic and fluid and electrolyte
balance fails resulting in uremia or azotemia. The incidence of ESRD has increased by
almost 8% per year for the past 5 years. Comorbid conditions that develop during
chronic renal insufficiency contribute to the high morbidity and mortality among patients
with ESRD.

Strategies for slowing progression and treating conditions underlying chronic

kidney disease include : Control of blood glucose, control of high blood pressure, fluid
retention, protein restriction, salt restriction, potassium restriction, phosphorus
restriction. Other important measures that a patient can take include carefully follow
prescribed regimens to control blood pressure and/or diabetes ,stop smoking and lose
excess weight.
Significance of the Case study

To client and the relatives

-To help them to understand the present condition and its complication.

To Student Nurse

-To help to understand the disease process of the patient and help those
identifying the primary needs of patient by recognizing such needs and health problems
arise that the group can now formulate an individualize care plan for the patient that
would address these needs and problems, effectively.

-To enhance the level of knowledge, skills and attitude on how to manage future
patient with same or similar disease.

To Reader

- Acquire more understanding about the present condition and its complication
and to increase their awareness.

College/ University

-To have reference to the certain disease.

Hospital/ Staff Nurse

-To enhance the appropriate nursing care to the future patient with the same
disease
Objectives of the case study

General:

The main goal of the group is to be able to learn and present the case of the
patient that would provide significant information.

Specific:

Client- Centered Objectives:

*to establish rapport to the patient

*to increase awareness on the risk factors of the disease

*to develop family and support system and distinguish their respective roles in
improving patients health status

*to involve them in promoting the health care of the patient

Nurse-Centered Objectives:

*to present the physical assessment obtained from the patient

*to interpret the laboratory result of the patient

*to discuss the Anatomy and Physiology of the organ involved in the patients disease.

*to discuss the surgical procedure performed to the patient

*to present a specific, measurable, attainable, realistic, and time-bounded nursing care
plan for the client.
Scope and limitation of the case study :

This study covers and focuses on the following :

*The rle group assigned at OMMC-medicine ward

*The rle group handled the patient for 3 days start on September 3,4,5 2012

*The rle group able to interview the patient

* The rle group able to read the chart and gather the data about the patients laboratory
exam and medical management
Chapter II: Assessment

A. Nursing Health History

a) Biographical Data

A case of G.R.V 52 y/o Female, Married. She is Tagalog , a Roman Catholic and
a High School graduate . She is currently residing at District 5, Manila.

b) Admission Data

She is admitted at Ospital ng Maynila Medical Center last September 1, 2012 at

exactly 3:15 PM , From Emergency room to Medicine ward via wheelchair and
Accompanied by her son.

c) Chief Complaint

Nilalagnat ako As verbalized by the client .

d) History of Present Illness

She is in twice a week Hemodialysis, last Hemodialysis was August 24, 2012.
Patient is abnormally in poor bronchial capacity. 7 days prior to consultation, patient
have productive cough with whitish sputum and has no consultation and no insulin due
or medication taken. 4 days prior to consultation , patient was noted to be agitated ,
unable to sleep with vomiting episodes , no consultation due or medication taken. In the
day of consultation patient has fever with agitation.

e) Past Medical History

She is known Diabetic for 4 years and had known CKD stage 5 since april 2011 .
Patient maintain medication initial Ferrous sulfate tab TID, EPO SC twice a week,
amlodipine 10 mg I tab OD, Simvastatin 40 mg/ tab and intermediate insulin. Patient
has no allergy to food and medication. Patient has no PTB result and no minor surgical
operation.
g) Gordons Functional Pattern

A .Health perception Health management Pattern

Before hospitalization:

Clients health rating from 1-10,1 is worst and 10 as best, is 8 because her lifestyle.

During Hospitalization:

Clients Health rating is 6 because her in the hospital and she cant do activities that
she want and what she usually do everyday.

B. Nutritional Metabolic Pattern

Before hospitalization

- States shes on a diet as tolerated meal pattern as follows: Eats breakfast of

rice ,egg, and coffee depend on what is the availability .Eats lunch at noon and eat
dinner in the evening with a highly seasoned foods and heavy meals like broiled meat,
and a cup of rice and drinks more than 8 glasses of water a day.

During hospitalization:

- States shes on a DD AND LSD meal pattern during his hospitalization Her
current weight.

C. Elimination Pattern

Before hospitalization:

-Bowel habits : Formed ,medium brown bowel movement ( BM ) once a day .

Denies mucous bloody or tarry stools.

Bladder habits: Voids approximately 3x dark yellow urine with current problems of
dysuria.
 During hospitalization:

-Bowel habits : Medium brown ( BM ) once a day

Bladder: Voids 2-3 per day. Dark yellow urine with current problems of dysuria.

D. Activity-Exercise Pattern

Before hospitalization

1.ADLs on an average day ; arises every 6:00 in the morning and eats breakfast
and do the household chores .In early and sometimes late afternoon eats lunch and
dinner. Sometimes feels fatigue after doing chores.

2. Hygiene: Showers every day

During Hospitalization

1 .ADLs: Always asleep and lying on his bed. Walks firmly to go to the comfort
room to urinate.

2. Hygiene: Has poor hygiene, cannot shower everyday by herself.

E. Sexuality- Reproduction Pattern

- States of disagreeing about having same sex relationship .And revealed that
having a gay/lesbian partner is restricted and prohibited in the society.

Special Problems: Denies history of any sexually transmitted diseases.

F. Sleep-Rest Pattern

Before hospitalization

-Sleeps at 11 pm in the evening and she wakes up at 6am in the morning.

Sometimes feels well rested when arises but sometimes not.Does not take any sleeping
pills. Enjoy watching television during siesta time and before going to sleep.
 During hospitalization

-Spending most of the time in sleeping.. States of reading newspaper when awake.

G.Cognitive-Perceptual Pattern

I.Sensory-Perceptual Pattern

1.Vision:Has normal vision .Denies itching, excessive tearing, redness, or trauma

to eyes

2.Hearing:Has normal hearing . Denies tinnitus , pain , and discharge.

3.Smell:Denies difficult with smell, pain, post nasal drip, sneezing, or frequent
nosebleeds.

4.Touch: Denies feeling of numb.

5.Taste: No difficulty tasting foods.

II. Cognitive Pattern

Before Hospitalization:

-Speaks clear without slur or slutter.

During Hospitalization:

-Cannot speak clearly.

H. Role-Relationship pattern

Before hospitalization:

-Describes relationship as the best part of her life right now. Explains her
relationship family members as friendly like .She lives with her family right now in
Intramuros ,Manila. Has casual relationship with housemates and relatives.
 During hospitalization

-She describes that her relationship with his family right now is not so good
because of her conditions. Its hard for her to cope up with her partner because of
some stress bothers to the the client and to her family

I. Self perception and self concept pattern

Before hospitalization:

-Describes self as typical person who can interact with other people. Sometimes
outgoing and likes to be around with people and want a silent and calm environment.

During hospitalization:

-After the client has been diagnosed and admitted to the hospital she became
irritable and hard to interact with other people .Because of this situation the client
doesnt like to mingle with other people around her and hates noisy environment.

J. Coping-stress tolerance Pattern

Before hospitalization

-Shares confidence with her husband and a few close friends. Divert her attention to
forget loneliness to her family. States she works the household chores when under
stress.

During hospitalization

-Most stressful time in life is her condition right now.

K. Value-Belief Pattern

Before hospitalization:

-She assures that every Sunday they will go to the church and praise the Lord with her
family and everynight she prays the rosary.
 During hospitalization:

-Cannot attend mass and pray the rosary anymore.

.
B. Physical Assessment

a. General Physical Survey

Clients posture is poor, she is wearing "T-shirt and shorts" and it is appropriate
rather than wearing clothes that are large or small. Her hygiene is poor, nails are dirty.
She has poor eye contact and has harshly voice and slowly speaks.

b. Vital signs

Patients Temperature of 36.8oC, Radial pulse of 79 bpm, Respiratory rate of 19

bpm and a Blood pressure of 110/70 mmHg during initial vital signs taking at 8 am. On
the second vital signs taking 11.30 am ,Her Temperature is 36.6, Radial pulse of 82
bpm, Respiratory rate of 19 bpm and a Blood pressure of 110/80 mmHg.

c. Physical Examination

HEAD

Skin is brown complexion with poor skin turgor; Skull is proportional to the size of the
body. Round with prominences; Scalp is white, free from lice and dandruff; Hair is color
black with a tincture of gray hair, shiny, tiny hair and free from dandruff; Face is oval in
shape and no involuntary movement.

EYES

Eyes are black, symmetrical, parallel and evenly placed; Sclera is clear and whitish in
color; Pupils are equally round reactive to light and accommodation (PERRLA); Lid
Margins is clear, without scaling or secretions; able to move eyes in full range of motion.

EARS
Ears are parallel and symmetrical. Auricles are free from nodules and lesions;Ear canal
is clean with scant amount of cerumen and a few cilia.able to hear whisper spoken
about two feet away.

NOSE

Nose is midline, symmetrical. Septum is straight; Nares are equal in size. She can
breathe in each nares when one is occluded at a time. Bleeding is not present.

MOUTH

Lips are pale and dry, and no lesions; Gums has no swelling, no retraction and no
discharge. Teeth have presence of dental carries. (Quantity of teeth unstated) ;Tongue
is color pink and freely movable.

NECK

The neck is proportion to the size of the body and head. No pain movement in any
direction. No palpable lumps, mass, areas of tenderness.

THORAX and LUNGS

The spine is straight and chest wall move symmetrically during respiration. No lumps,
mass, and areas of tenderness. Lung sounds can be heard clearly.

HEART

Aortic valve, pulmonic valve and tricuspid valve have no pulsations. Pulsations visible
and palpable at the apical area (LMCL).Pitched sounds of lub and dub are audible in
all areas but loudest at apical area. Cardiac rate are normal.

BREAST

There are no mass or lumps, no areas of tenderness, brown in color, round areola, color
darker than surrounding skin, symmetrical. No masses and area of tenderness. Nipples
are round, equal in size, dark in color and no masses and area of tenderness.

ABDOMEN
Color is uniform, flat and the color is the same as the surrounding skin. Borborygmi
sounds can be heard. Tympanic sound is heard over the left upper quadrant due to the
presence of stomach and Dull sound heard over the right upper quadrant due to the
presence of liver in that area. Liver is palpable at right upper quadrant.

UPPER EXTREMITIES

In the arms muscle appears equal with good muscle tone and no presence of visible
veins. Palms and dorsal surfaces are cold. Nails are transparent, smooth, and convex
with pink nail beds and white translucent tips. There are five fingers in each hand. The
capillary refill was returned about 3 seconds. Shoulders, Wrist, Fingers are freely
movable with difficulty.

LOWER EXTREMITIES

In the legs, knees, ankles and toes muscle appears equal with good muscle tone and
no presence of visible veins. Nails are transparent, smooth, and convex with pink nail
beds and white translucent tips. There are five fingers in each foot. The capillary refill
was returned about 3 seconds and freely movable with difficulty.
C. Laboratory and Diagnostic exam

Hematology clinical laboratory test

- are used to examine blood and blood components to determine if they are within
normal limits.Values outside the normal limits might be signs of a disease.Hematology
tests count the number of white and red blood cells and platelets. In addition, these
tests measure the time necessary for blood to clot and the capability of blood to carry
oxygen throughout the body. Hematology tests also determine inflammation and
infection in the patient and the type of infection.

Clinical chemistry

-(also known as chemical pathology and clinical biochemistry) is the area of clinical
pathology that is generally concerned with analysis of bodily fluids.

The discipline originated in the late 19th century with the use of simple chemical tests
for various components of blood and urine. Subsequent to this, other techniques were
applied including the use and measurement of enzyme activities, spectrophotometry,
electrophoresis, and immunoassay.

Most current laboratories are now highly automated to accommodate the high workload
typical of a hospital laboratory. Tests performed are closely monitored and quality
controlled.

All biochemical tests come under chemical pathology. These are performed on any kind
of body fluid, but mostly on serum or plasma. Serum is the yellow watery part of blood
that is left after blood has been allowed to clot and all blood cells have been removed.
This is most easily done by centrifugation, which packs the denser blood cells and
platelets to the bottom of the centrifuge tube, leaving the liquid serum fraction resting
above the packed cells. This initial step before analysis has recently been included in
instruments that operate on the "integrated system" principle. Plasma is in essence the
same as serum, but is obtained by centrifuging the blood without clotting. Plasma is
obtained by centrifugation before clotting occurs. The type of test required dictates what
type of sample is used.

Cross-matching

Blood in transfusion medicine, refers to the complex testing that is performed prior to a
blood transfusion, to determine if the donor's blood is compatible with the blood of an
intended recipient, or to identify matches for organ transplants. Cross-matching is
usually performed only after other, less complex tests have not excluded compatibility.
Blood compatibility has many aspects, and is determined not only by the blood
types (O, A, B, AB), but also by blood factors, (Rh, Kell, etc.).

Cross-matching is done by a certified laboratory technologist, in a laboratory. It can be

done electronically, with a computer database, or serologically. Simpler tests may be
used to determine blood type (only), or to screen for antibodies (only). (indirect Coombs
test).
Hematology report

August 31, 2012

Results Normal values Analysis

WBC 4 4.8-10.8 Result was below normal, this
indicate serious infection
NEUTROPHIL 56.5 55-75 Normal
S
LYMPHOCYT 39.2 20-30 Result was above normal, indicating
ES bacterial infection
MONOCYTES 4.0 0-7 Normal
EOSINOPHILS 0.3 0-3 Normal
BASOPHILS 0 0-1 Normal
RBC 3.87 4.00-6.20 Result was below normal, This
indicates alteration in Erythropoeitin
production secondary to renal
function
HGB 12.6 12.0-16.0 Normal
HCT 36.1 37.0-47.0 Result was below normal, thus
showing anemia r/t insufficient RBC
production
MCV 93.4 80.0-90.0 Result was above normal, thus shows
the presence of hemolytic anemia
MCH 32.6 27.0-31.0 Result was above normal, thus shows
the presence of anemia
MCHC 34.9 32.0-36.0 Normal
RDW 19.5 11.5-14.5 Result was above normal. This show
iron deficiency anemia
PLATELET 502 150-400 Result was above normal, indicates
renal failure
NRBC 0.00-0.00
Hematology report

September 1, 2012

Results Normal Values Analysis

WBC 39.5 4.8-10.8 Result was above the normal range .

this show the presence of inflammation
and infection.
NEUTROPHI 93 55-75 Result was above the normal level.
LS This shows bacterial infection.
LYMPHOCYT 5 20-30 Result was below the normal range.
ES This shows increased infection.
MONOCYTES 2 0-7 Normal
EOSINOPHILS 0 0-3 Normal
BASOPHILS 0 0-1 Normal
RBC 3.73 4.00-6.20 Result was below the normal range.
This indicates alteration in
Erythropoeitin production secondary to
renal function.
HGB 11.4 12.0-16.0 Result was below normal. This shows
the decrease in oxygen carrying
capacity of the blood secondary low
hct .
HCT 35.2 37.0-47.0 Result was below normal, thus
showing anemia r/t insufficient RBC
production
MCV 94.1 80.0-90.0 Result was above normal, thus shows
the presence of hemolytic anemia
MCH 30.4 27.0-31.0 Normal
MCHC 32.3 32.0-36.0 Normal
RDW 19.7 11.5-14.5 Result was above normal. This show
iron deficiency anemia.
PLATELET 201 150-400 Normal
NRBC 0.00-0.00
Clinical chemistry
August 31, 2012
Test Result Normal values Analysis
Total bili 8.5-25.6 umol/L
Direct bili 0-3.4 umol/L
Indirect bili 8.5-22.2 umol/L
Total protein 6.2-8.5 g/dl
Albumin 3.5-5.0 g/dl
Globulin 2.7-3.2 g/dl
A/G ratio 1.29-1.65
Alkaline 100-290 U/L
phosphatase
SGPT 0-38.0 U/L
SGOT 0-40 IU/L
Creatinine 0.7-1.4 mg/dl
Phosphorus 1.06 0.84-1.45 Normal
mmol/L
Ionized calcium 1.1-1.4 mmol/L
Amylase 25-96 U/L
Lipase 10-150 U/L
Calcium 10.1 8.5-10.4 mg/dl Normal
Creatinine 7.00 0.44-1.03 mg/dl Result was above normal, this
indicate renal malfunction. The kidney
cannot excrete nitrogenous waste
product of protein leading to it
accumulation in the blood.

Clinical chemistry
September 1, 2012
Test Result Normal values Analysis
Alkaline phosphate 35-129 U/L
Total bili 0-17.1 umol/L
Direct bili 0-5.1 umol/L
Indirect bili
Total protein 66-87 g/L
Albumin 34-48 g/L
Globulin 20-38 g/L
Sodium 134-145 mmol/L
Potassium 4.39 3.4 -5 mmol/L Normal
Chloride 93-109 mmol/L

D. Course in the Ward

September 3, 2012
Patient has D5W 1L to run for 8 hours
Continue medication (initial Ferrous Sulfate Tab TID, EPO SC twice a week,
Amlodipine 10 mg I tab OD, Simvastatin 40 mg/tab and intermediate insulin).
On Low salt , low fat diet , Diabetic diet
Blood transfusion
Vital signs every hour
With Foley catheter
Placed on Moderate high back rest
Accurate Intake and output

September 4, 2012
Patient has D5W 1L to run for 8 hours
Continue Medication (initial Ferrous Sulfate Tab TID, EPO SC twice a week,
Amlodipine 10 mg I tab OD, Simvastatin 40 mg/tab and intermediate insulin).
On low salt , low fat diet, Diabetic diet
With Foley catheter
Placed on Moderate High back rest
Remove Foley catheter
Accurate Intake and Output

September 5, 2012
Patient has D5W 1L to run for 8 hours
Continue Medication (initial Ferrous Sulfate Tab TID, EPO SC twice a week,
Amlodipine 10 mg I tab OD, Simvastatin 40 mg/tab and intermediate insulin).
On low salt , low fat diet , Diabetic diet
Placed on Moderate high back rest
Accurate intake and output
Chapter III: Clinical Discussion and Description of the Disease

A. Definition and Description of the Disease

 Chronic Kidney Disease is a chronic progressive and irreversible disease of the
kidneys. Chronic kidney disease is an umbrella term that describes kidney damage or a
decrease in the Glomerular filtration rate (GFR) for three or more months. Untreated
Chronic Kidney Disease can result in end-stage renal disease (ESRD) and necessitate
renal replacement therapy (dialysis or kidney transplantation).

Diabetes is the primary cause of Chronic Kidney Disease, second leading cause
is hypertension followed by Glomerulonephritis and pyelonephritis.

B. ANATOMY AND PHYSIOLOGY

The Kidney
 The main functional unit of the kidney is the nephron. There are approximately
one million nephrons per kidney. The role of nephrons is to make urine by:

Filtering blood of small molecules and ions such as water, salt, glucose and other
solutes including urea. Large macromolecules like proteins are untouched.
Recycling the required quantities of useful solutes which then re-enter the
bloodstream. (A process called reabsorption)
Allowing surplus or waste molecules/ions to flow from the tubules ureter as urine.
 Nephrons are the basic structural and functional units of the kidney. They consist
of a network of tubules and canals specialized in filtration.

The kidney is responsible for maintaining fluid balance within the body. The basic
structural and functional units of the kidneys are the nephrons. Each nephron is made of
intricately interwoven capillaries and drainage canals to filter wastes, macromolecules,
and ions from the blood to urine. The approximately 1 million nephrons in each human
kidney form 10-20 cone-shaped tissue units called renal pyramids that span both the
inner and outer portions of the kidney, the renal medulla and renal cortex

A. Renal Vein

This has a large diameter and a thin wall. It carries blood away from the kidney
and back to the right hand side of the heart. Blood in the kidney has had all its urea
removed. Urea is produced by your liver to get rid of excess amino-acids. Blood in the
renal vein also has exactly the right amount of water and salts. This is because the
kidney gets rid of excess water and salts. The kidney is controlled by the brain. A
hormone in our blood called Anti-Diuretic Hormone (ADH for short) is used to control
exactly how much water is excreted. This blood vessel supplies blood to the kidney from
the left hand side of the heart. This blood must contain glucose and oxygen because the
kidney has to work hard producing urine. Blood in the renal artery must have sufficient
pressure or the kidney will not be able to filter the blood. Blood supplied to the kidney
contains a toxic product called urea which must be removed from the blood. It may have
too much salt and too much water. The kidney removes these excess materials; that is
its function.

B. Renal Artery

This blood vessel supplies blood to the kidney from the left hand side of the
heart. This blood must contain glucose and oxygen because the kidney has to work
hard producing urine. Blood in the renal artery must have sufficient pressure or the
kidney will not be able to filter the blood. Blood supplied to the kidney contains a toxic
product called urea which must be removed from the blood. It may have too much salt
and too much water. The kidney removes these excess materials; that are its function

C. Pelvis

This is the region of the kidney where urine collects. If you are very unlucky, you
may develop kidney stones. Sometimes the salts in the urine crystallise in the pelvis
and form a solid mass which prevents urine from draining out of the medulla of the
kidney. You will need treatment: see your doctor.

D. Ureter

This one is easy peasy: the ureter carries the urine down to the bladder. It does
this 24 hours per day, but fortunately the urine can be stored in a bladder so that it is not
necessary to wear a nappy!

E. Medulla

The medulla is the inside part of the kidney. It is shown in green in the diagram,
but in real life it is a very dark red colour. This is where the amount of salt and water in
your urine is controlled. It consists of billions of loops of Henl. These work very hard
pumping sodium ions. ADH makes the loops work harder to pump more sodium ions.
The result of this is that very concentrated urine is produced.The opposite of an anti-
diuretic is a "diuretic". Alcohol and tea are diuretics.

F. Cortex

The cortex is the outer part of the kidney. This is where blood is filtered. We call
this process "ultra-filtration" or "high pressure filtration" because it only works if the
blood entering the kidney in the renal artery is at high pressure. Billions of glomeruli are
found in the cortex. A glomerulus is a tiny ball of capillaries. Each glomerulus is
surrounded by a "Bowman's Capsule". Glomeruli leak. Things like red blood cells, white
blood cells, platelets and fibrinogen stay in the blood vessels. Most of the plasma leaks
out into the Bowman's capsules. This is about 160 litres of liquid every 24 hours.Most of
this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and put back into
the blood.

G. Glomerulus and Bowman's Capsule

This is where ultra-filtration takes place. Blood from the renal artery is forced into
the glomerulus under high pressure. Most of the liquid is forced out of the glomerulus
into the Bowman's capsule which surrounds it. This does not work properly in people
who have very low blood pressure. Proximal Convoluted Tubules Proximal means "near
to" and convoluted means "coiled up" so this is the coiled up tube near to the Bowman's
capsule.

This is the place where all that useful glucose is re-absorbed from the ultra-
filtrate and put back into the blood. If the glucose was not absorbed it would end up in
your urine. This happens in people who are suffering from diabetes.

H. Loop of Henl

This part of the nephron is where water is reabsorbed. Kidney cells in this region
spend all their time pumping sodium ions. This makes the medulla very salty; you could
say that this is a region of very low water concentration. If you remember the definition
of osmosis, you will realise that water will pass from a region of high water
concentration (the ultra-filtrate and urine) into a region of low water concentration (the
medulla) through cell membranes which are semi-permeable.

I. Distal Convoluted Tubules

 Distal means "distant" so it is at the other end of the nephron from the Bowman's
capsule. This is where most of the salts in the ultra-filtrate are re-absorbed.

J. Collecting Duct

Collecting ducts run through the medulla and are surrounded by loops of Henl.
The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and salts are
removed from it. Although our kidneys make about 160 litres of urine every 24 hours, we
only produce about litre of urine.It is called a collecting duct because it collects the
liquid produced by lots of nephrons.

PATHOPHYSIOLOGY : CKD secondary to DM II

 The underlying pathophysiology defect in type 2 diabetes is characterized by the
following three disorders (1) peripheral resistance to insulin, especially in muscles cells:
(2) increased production of glucose by the liver, and (3) altered pancreatic secretion.
Increased tissue resistance to insulin generally occurs first and eventually followed by
impaired insulin secretions. The pancreas produces insulin, yet insulin resistance
prevents its proper use at the cellular level. Glucose cannot enter target cells and
accumulates in the blood streams, resulting in hyperglycemia. The high blood glucose
levels often stimulate an increase in insulin production by the pancreas: thus. Type 2
diabetic individuals often have excessive insulin production (hyperinsulinemia).

Insulin resistance refers to tissue sensitivity to insulin. Intracellular reaction are

diminished, making insulin less effective at stimulating glucose uptake by the tissues
and regulating glucose release by the liver.
 If blood glucose levels are elevated consistently for a significant period of time,
the kidneys filtration mechanism is stressed, allowing blood proteins to leak into the
urine. As a result, the pressure in the blood vessels of the kidney increases. It is thought
that the elevated pressure serves as the stimulus the level of nephropathy.

The earliest detectable change in the course of diabetic nephropathy is a

thickening in the glomerulus. At this stage, the kidney may start allowing more albumin
(protein) than normal in the urine, and this can be detected by sensitive tests for
albumin.

As diabetic nephropathy progresses, increasing numbers of glomeruli are

destroyed. Now the amounts of albumin being excreted in the urine increases, and may
be detected by ordinary urinalysis techniques. At this stage, a kidney biopsy clearly
shows diabetic nephropathy and eventually leads to Chronic renal failure.

D. Medical Surgical Management

Antihypertensive and cardiovascular agents are given to manage hypertension
by intravascular volume control
 Hemodialysis is used for patients who are acutely ill and require short-term
dialysis (days-weeks) and for patients with advance CKD and ESRD who require
long term or permanent renal replacement therapy. Hemodialysis prevents death
but does not cure renal disease and does not compensate for the loss of
endocrine or metabolic activities of the kidney.

A. List of Prioritization

1. Imbalance Nutrition less than body requirement related to catabolic state, anorexia

and malnutrition 2O to renal failure.

2. Deficient knowledge related to lack of integration of treatment plan into daily

activities.
3. Risk for situational low self-esteem related to dependency, role changes, change in

body image and change in sexual function

C. Discharge Planning

Medication
Advised patient to take Vitamin C and Antihypertensive drugs as
prescribed
Exercise
Advised patient to do light exercise like walking
Treatment
Emphasized the schedule of patients Hemodialysis
Health Teaching
Emphasized the importance of proper hygiene
Out Patient Department
Emphasized the importance of regular check-up and seeking medical
advise.
Diet
Advised patient to eat balanced diet, avoid salty and fatty foods
Signs and symptoms
Provide knowledge about possible signs and symptoms of Chronic Kidney
Disease
Spiritual
Emphasized that prayer is helpful in reducing anxiety.