The Doctor’s Clinic and Hospital School Foundation Inc.

Gen. San Drive, City of Koronadal, South Cotabato

A Case Study
Of
Chronic Renal Failure

Presented to the 2nd year CI’s of

The Doctor’s Clinic and Hospital School Foundation Inc.

Presented by:

Abas, Hyran Plana, Haziel

Allado , Mia Christine Plana, Leseil
Bajoyo, Jeralyn C. Quinitio, Ailyn
Basco, Keith Melvin Rocio, Rechelle
Menorias, Raiza Mae Sadang, Cymonette
Perbillo, Jesus Edson Santos, Ryan
Perida, Dyte Silvederio, Jehan
Pingoy, Sheina Mae Tediong, Almie

Date: October 13, 2008

Introduction

Chronic renal failure, also called “Chronic kidney disease” is a progressive

reduction of functioning renal tissue such that the remaining kidney mass can no
longer maintain the body’s internal environment. It is also defined as a
permanent reduction in glomerular filtration rate (GFR) sufficient to produce
detectable alteration in well-being and organ function. The GRF usually occurs
below 25ml/min. There are four stages of decreased renal function may be
visualized: Silent- GFR up to 50 ml/min, Renal insufficiency-GFR 25 to 50
ml/min, Renal failure-GFR 5 to 25 ml/min., End-stage renal failure-GFR less than
5 ml/min.

Chronic renal failure is also a condition in which kidney function gradually

declines, until the kidneys are unable to filter wastes from the body, maintain the
proper balance of water and chemicals such as sodium and potassium in the
blood stream, or produce urine. Chronic renal failure can occur in anyone with an
illness or injury that affects the kidneys. It is more likely to affect people who are
middle-aged and older.

The most common causes of chronic renal failure are diseases or

illnesses that damage the kidneys little by little for many years. These include
high blood pressure, diabetes mellitus, polycystic kidney disease, obstructions of
the urinary tract, glomerulonephritis, certain cancers, autoimmune disorders such
as systemic lupus erythematosus, and diseases of the heart or lungs. Using pain
killing medications for a long period time may also damage the kidneys and
cause chronic renal failure.

Among patients with ESRD aged 65 years and older, the mortality rates
are 6 times higher than in the general population. In 2003, over 69,000 dialysis
patients enrolled in the ESRD program died (annual adjusted mortality rate of
210.7 per 1000 patient-years at risk for the dialysis population, which represents
a 14% decrease since peaking at 244.5 per 1000 patient-years in 1988). The
highest mortality rate is within the first 6 months of initiating dialysis, which then
tends to improve over the next 6 months, before increasing gradually over the
next 4 years.

Because chronic renal failure progresses gradually, symptoms may be so

mild that the patient doesn’t recognize that he or she has a serious health
problem. At first, symptoms include frequent urination, especially at night. The
urine is dilute, which means it has high water content, making it appear pale to
clear on color. As the kidneys fail, waste products and fluids build up in the blood
stream, and then the excess fluid causes swelling (edema), usually in the hands,
feet, face, and abdomen. The extra fluid also causes the blood pressure to rise.
There are also symptoms arises just like nausea, fatigue, foul smelling breath,
joint pain, reduce urination, blood in the urine, confusion, seizures, headaches,
itching, pain in the kidney area, and a yellowish-brown appearance to the skin.
CHRONIC RENAL FAILURE can lead to coma and death.
Objectives:

General:
At the end of this case presentation, the students will be able to enhance
their knowledge about the nature of “Chronic Renal Failure”.

Specifically, the students will be able to:

1. Define CRF (Chronic Renal Failure) and other disease related terms.
2. Enumerate the signs and symptoms of chronic renal failure.
3. Know the importance of physical assessment
4. Understand the doctor’s order and its rationale.
5. Interpret the laboratory examination results and its implication.
6. Understand the anatomy and physiology of the kidney.
7. Know appropriate care, diet and containing management.
Acknowledgement

For almost four day pre- clinical exposure to the Doctor’s Clinic and
Hospital Inc. we would like to give thanks to the following person; first is to the
member of group 5, specially to Ms. Raiza Mae F. Menorias for leading the group
very well, to Ms. Jeralyn C. Bajoyo serves as the group’s editor- in- chief for this
manuscript, for distributing individual assignments for each member and for
collecting data which is important for this case study, and for Ms. Hyran Abas,
Ms. Mia Christine Allado and Mr. Keith Melvin Basco, serves as a executive
assistant to finished this manuscript and to all the member who participated well,
thank you to all of us.
Second, to our beloved and supporting Clinical Instructor, Ms. April E.
Tumbagahan RN., who guided and taught us proper monitoring of vital signs,
intake and out put, reading and computing intravenous level and how to
established proper rapport both normal and psychotic patient. Third, to the faculty
and staff of the hospital, who allowed us to get important data regarding to our
patient. Fourth, to the patient who allowed us to give information about herself,
and for being participative and cooperative. Thank you, thank you, to all of you
guys, ma’am and sir! Even in a short period of time we’ve learned a lot from you.
Small things but a lot of learning. Learning’s that cannot be forgotten until we
succeed this journey.
Most of all we give thanks to our parents who are providing and supporting
us in our studies. To almighty God, thank you, for keeping us safe throughout the
duration of our exposure.
THANK YOU!!
Definition of Terms

1. Acidosis- a condition in which the acidity of the blood and body fluids
rises to an abnormally high level as a result of a failure in the
mechanisms that regulate the acid base balance in the body.
2. Anuria- a failure of the kidney to produce urine, which may result from
a disorder that causes a prolonged drop in blood pressure.
3. Azotemia- the accumulation of nitrogenous waste products. Chiefly
urea, in the blood in the hall mark or renal failure.
4. Chronic- Slowly developing, lingering.
5. Dialysis- the use of semipermeable membrane to separate large and
small molecules by selective diffusion. Starch and proteins are large
molecules while salts, glucose and amino acids are small molecules.
6. Electrolytes- are substances found in extra cellular and intracellular
fluid that dissociate into electrically charged particles known as ions.
Ions that carry a negative charge are called cations, those that carry a
negative charge are called anions.
7. End- Stage Renal Disease (ESRD)- histologic findings of an end-
stage kidney include a reduction in renal capillaries and scarring in the
glomeruli.
8. Glomerulus- A coil of minute arterial capillaries held together by
scanty connective tissue.
9. Hemodialysis- A process of removing metabolic waste products, other
poisons, and excess fluids from the blood and replacing essential
blood constituents by a process of diffusing through a semi- permeable
membrane.
10. Homeostasis- described the elative constancy of the internal
processes of the body, such as blood temperature, blood glucose, and
fluid and electrolytes balance.
11. Hyperkalemia- refers to an increase in serum level of potassium in
excess of (5.50 mmol/L).
12. Hypertrophy- is an increase in the size of an organ or tissue resulting
from an increase in the size of cell.
13. Nephron- The basic structure and functional unit of the kidney.
14. Peritoneum- The delicate, smooth, transparent, serous membrane
that lines the abdominal and pelvic cavities and reflected over the
organs contained in them thus forming a sac.
15. Polyuria- refers to the reproduction of abnormally large amount of
urine by the kidney.
16. Prognosis- A forecast of the probable course, duration and
termination of the disease.
17. Renal- Pertaining to the kidney.
18. Renal Failure- which refers to slows or stops of the filtration of blood,
causing toxic waste products to build up in the blood.
19. Tubule- A small tube, straight in the kidney medulla conveying urine to
the kidney pelvis.
20. Urinary bladder- A sac like pelvic organ that serves as a reservoir for
the collection of the urine to be voided through the urethra.
21. Uremia- means urine in blood.
22. Urologist- A physician who specialize urology.
23. Urology- the branch of medical science that deals with disorders of
the female urinary tract and the male genitourinary tract.
Clinical Contents
A. Patients Data
• Demographic Data
Name: Mrs. Lee
Age: 43 years old
Birth date: July 9, 1964
Birth Place: Iloilo city
Sex: Female
Address: BLK2, Lot 3 Sueno Village, Koronadal, South
Cotabato
Religion: Roman Catholic
Nationality: Filipino
Tribe: Ilonggo
Status: Married
Occupation: Housewife
Educational attainment: High School Graduate

• History of Past illness

The patient had been acquired chicken pox during her childhood.
She also experienced headache and cough. In 2000, she was admitted
at Provincial Hospital, because of the diagnosed case of rheumatism.
In May 9, 2007, she was admitted at TDCHFI, with the diagnosis of
Diabetes. In May 12, 2008, she was confined at TDCHFI due to
hypertension, Chronic Renal Failure, and Diabetes Mellitus. In the
same year, last August 29, she was admitted again because of
hypertension, anemia, and Chronic Renal Failure. According to her she
has no allergies in terms of food, drugs, etc.
• History of present illness
It was on September 22, 2008, 1:25am were the patient was
admitted at Doctor’s Clinic and Hospital Inc. with the chief
complaint of Dyspnea. And it was referred to DR. Quiambao. A
diagnosed case of “Chronic Renal Failure” > 1 year but refused
dialysis. Transfusion 3 bags of blood 3 weeks PTA progressive
dyspnea noted X2days.
She was experiencing difficulty of breathing that’s why, her
husband bring her to the hospital, to seek treatment.

• Reason of admission:
For management and treatment.

• Admitting diagnosis: “Chronic Renal Failure”

• Final diagnosis:
“Chronic kidney Disease 2°CGN and
Hypertension II”
Physical Assessment
Date: September 23, 2008
Height: 5 ft.2 inch.
Weight: 53 kls.
Skin
Inspection:
• Brown complexion
• Freckles noted
• Wrinkle skin noted
• Scaly skin noted
• Bruises noted

Palpation:
• Normally warm
• Poor skin turgor (for more than 2-3 second)
• Dry skin noted
Head
Inspection:
• The skull and face are symmetric
• Hair are well distributed
• Shiny hair noted
Palpation:
• Presence of flakes on the scalp
• No lesions and deformities noted
Eyes
Inspection:
• Symmetrical in size and shape
• Well distribution of the eyebrow
 • Presence of eye bag
• Normal accommodation
• Constrict rapidly to light
Ears and hearing
Inspection:
• Size of the pinna is symmetric to the other
• No lesion noted
• Presence of cerumen noted
• Skin color is normal
• Earlobe is in normal contour
• Hearing is normal
• No drainage noted

Nose
Inspection:
• Nasal septum is straight and not perforated
• Airways are patent
• No presence of secretion
Mouth
Inspection:
• Lips are dry and pail
• Poor dental hygiene
• Dental caries noted
• Uvula is symmetrical
• Cranial nerve 12 and 9 is normal (hypoglossal and
Glossopharyngeal)

Neck
Inspection:
• Movement and size of the thyroid is normal
 • Weak muscle strength
• Veins are visible
Palpation:
• Irregularities in the pulsation of carotid arteries
• No palpable mass noted
Heart
Auscultation:
• Irregularity of cardiac rhythm noted (dysrhythmia)
• Weak rhythm of the heart
Lungs
Inspection:
• Thorax is normally symmetric
Auscultation:
• Pitch sound is normal (vesicular sound)
Chest
Inspection:
• Inverted nipple noted
• Normal chest expansion
• Symmetry in size
• Wrinkle skin on the nipple surrounding areola
• Areola symmetrical to the other

Abdomen
Inspection:
• Scars noted
• Poor hygiene of the umbilicus
• Slightly rounded
Auscultation:
• Normal bowel movement (according to the patient)
Upper Extremities
Inspection:
• Dry and wrinkle skin
• Skin bruise noted
• Joints moves normally
• Hands can grip normally
• Poor nail hygiene

Palpation:
• Capillary refill is normal (less than 1-2 second)
• Without presence of Edema
Lower Extremities
Inspection:
• Dry and scaly skin
• Presence of hair noted
• Cracked heels
• Poor nail hygiene
• Normal mobility noted
Palpation:
• Edema noted on both lower leg
• Poor skin turgor
• Weak pedal pulsation (58bpm)
Vital signs
Temperature: 36.8C°
Pulse rate: 61bpm
Respiratory rate: 17cpm
Blood pressure: 120/90mmHg
Anatomy and Physiology

The kidneys are a pair of bean- shaped organs that lie on either side of
the spine in the lower middle of the back. Each kidney weighs about ¼ pound
and contains approximately one million filtering units called nephrons. Each
nephron is made of glomerulus and a tubule. The glomerulus is a miniature
filtering or sieving device while the tubule is a tiny tube like structure attached to
the glomerulus.

The kidneys are connected to the urinary bladder by tubes called ureters.
Urine is stored in the urinary bladder until the bladder is emptied by urinating.
The bladder is connected to the outside of the body by another tube like structure
called urethra.
 The main function of the kidneys is to remove waste products and
water from the blood. The kidneys process about 200 liters of blood every day
and produce about two liters of urine. The waste products are generated from
normal metabolic processes including the breakdown of active tissues, ingested
foods, and other substances. The kidney allow consumption of a variety of foods,
drugs, vitamins, and supplements, additives, and excess fluid without worry that
toxic by products will build up to harmful levels. The kidneys also play a major
role in regulating levels of various minerals such as calcium, sodium, and
potassium in the blood. The first process by which the kidney produce urine is
called glomerular filtration. Blood enters the glomerulus under high pressure,
forcing substances across the leaky endothelial- capsular membrane into the
nepron. The substances that are filtered into the renal tubule include water, small
proteins, salts, glucose, nitrogenous waste products such as urea and other
metabolic waste products and drugs metabolites.
Chief among these wastes are the nitrogen-containing compounds urea
and uric acid, which result from the breakdown of proteins and nucleic acids.
Life-threatening illnesses occur when too many of these waste products
accumulate in the bloodstream. Fortunately, a healthy kidney can easily rid the
body of these substances.

In addition to clean the blood, the kidneys perform several other essential
functions. One such activity is regulation of the amount of water contained in the
blood. This process is influenced by antidiuretic hormone (ADH), also called
vasopressin, which is produced in the hypothalamus (a part of the brain that
regulates many internal functions) and stored in the nearby pituitary gland.
Receptors in the brain monitor the blood’s water concentration. When the amount
of salt and other substances in the blood becomes too high, the pituitary gland
releases ADH into the bloodstream. When it enters the kidney, ADH makes the
walls of the renal tubules and collecting ducts more permeable to water, so that
more water is reabsorbed into the bloodstream.

The kidney also adjusts the body's acid-base balance to prevent such
blood disorders as acidosis and alkalosis, both of which impair the functioning of
the central nervous system. If the blood is too acidic, meaning that there is an
excess of hydrogen ions, the kidney moves these ions to the urine through the
process of tubular secretion. An additional function of the kidney is the
processing of vitamin D; the kidney converts this vitamin to an active form that
stimulates bone development.
Doctor’s order

Progress note Doctor’s Order Rationale

9/22/08 Please admit ( Dr.
1:25am Quiambao)
TPR Q4
I and O q shift
D5 Water 1 L at KVO
Labs: CBC, U/A, Na, K
Meds:
1.)Capoten 25 mg. SL now
2.)Furosemide 40 mg. IVTT
q OD
O inhalation at 2-3 L/h Prn
V/s q 2 and chart
Pls. inform Dr. Quiambao
>for treatment and management.
>for proper monitoring
> to monitor fluid
>to detect anemia of renal failure
&inflammatory, to established
diagnosis &identify renal
complication, to detect
hyponatremia / hypernatremia, to
detect hypokalemia /
hyperkalemia
>anti hypertensive
>anti hypertensive

9/22/08 ABG Now

2 am T.O. Dr.
Quiambao

2:30 am Nifedipine 5 mg SL Q 4 for >anti hypertensive

BP=260/150 BP> 180/100
↑Furosemide 60 mg Q 8 IV
T. O: Dr.
Quiambao
9/22/08 CRF Diet
9:20 am -TF: PNSS 1L to KVO
-For chest x-ray PA view
-For serum creatinine today >to established the diagnosis &
-V/S q 4 hr and record. measure intrinsic renal function.
-I and O q 4 hr and record. >proper monitoring of output
-Resume PO maintenance
meds:
Amlodipine (Amcar) 10
mg 1 tab OD
Neobloc 100 mg 1 tab
BID
NaHCO3 650 mg 1 tab >neutralizes excess acid
TID Pc
Tums 500 mg 1 cap BID Ac >calcium Supplement
NaHCO3 25mg slow IVTT
now
Furosemide 60 mg IVTT
post NaHCO3
9/23/08 Erythropoetin 4,000 IU SQ >enhancing RBC production
9:20am now
9:35 am No potassium containing To decrease potassium and to
food prevent hyperkalemia
T.O Dr.
Qiuambao

LABORATORY AND DIAGNOSIS

 ARTERIAL BLOOD RESULT
Name: Mrs. Lee Age: 43 Sex: F Hosp: TDCHI
RM./Bed: FW Requested by: Dr. Quiambao Date: 9/22/08
Time: 2:35 am
FIO2: 2-3 cpm
RR : 20 cpm

pH =7.32 (7.35-7.45)
PCO2 =25.4 (35-45 mmHg)
PO2 = 107.4 (80-100 mmHg)
HCO3 =13.1 (22-26 mEq/L)
B. E. = -10 9 (± 2mEq /L)
Q2 Sat. 97.7 % (97%)
T40 HCO3_____

Interpretation:
Arterial Blood Gas Result
• Adequate oxygenation= oxygenation
• Partially compensated, metabolic
 THE DOCTOR’S CLINIC AND HOSPITAL,INC.
City of Koronadal, South Cotabato
Department of Clinical Laboratories
Clinical Chemistry Section
Name: Mrs. Lee Test requested: 9/22/08
1:50:20 am
Age/sex: 43(f) Result verified: 9/22/08 3:27:53am
Room no./ Ward: FMW-/M2
Physician: Reyes-Quiambao, Jennifer Lee

Specimen: Serum
Examination Result Normal Value Implication
Potassium (K+) 5.57 3.50- 5.50mmol/L Abnormal
Hyperkalemia
Sodium (Na++) 135.60 135.00- Normal
145.00mmol/L
Remarks:

THE DOCTOR’S CLINIC AND HOSPITAL, INC.

City of Koronadal, South Cotabato
Department of Clinical Laboratories
 Hematology Section
Name: Mrs. Lee Test requested: 9/22/08
1:50:22 am
Age/sex: 43(f) Result verified: 9/22/08 3:25:59am
Room no./ Ward: FMW-/M2
Pyician: Reyes-Quiambao, Jennifer Lee

Specimen: Blood
Complete Blood Count ( CBC)
Examination Result Normal value Implication
Hemoglobin 106.0 120.00- Low Hemoglobin count
0 160.00 g/L >anemia from blood loss
Hematocrit 31.10 36.00- 48.00 Below normal
vol.% anemia
Erythrocytes 3.73 4.00- 5.50 x Below normal
(RBC) 10^12/L Anemia

Leukocytes 11.50 4.50- 11.00 x Above normal range

(WBC) 10^g/L
Differential Count
Segmented 0.77 0.50- 0.70 Above normal range
Nuetrophils
Bands (stab cell) 0.00-0.07
Lymphocytes 0.20 0.25- 0.40 Below normal
>depressed immune
system
Monocytes 0.03- 0.09
Eosinophil 0.03 0.01- 0.03 Normal
Basophil 0.00- 0.01
Platelet count 150.00-
350.00
x10^g/L
MCV fL
MCH Pg
MCHC %
 THE DOCTOR’S CLINIC AND HOSPITAL, INC.
City of Koronadal, South Cotabato
Department of Clinical Laboratories
Name: Mrs. Lee Test requested: 9/22/08 9:41:41am
Age/sex: 43(f) Result verified: 9/22/08 11:19:02am
Room no./ Ward: FMW-/M2
Pyician: Reyes-Quiambao, Jennifer Lee

Specimen: Serum
Examination Result (g.l) Normal Result Normal Implication
Value (g.l) (c.u.) value (c.u.)
Creatinine 104.10 53.00- 11.81 0.60- Abnormal
97.00 1.10mg/ dL Infection
umol/L
Remarks

Radiology: 9/22/08
x-ray chest:
=There are homogenous specifications seen in both middle- line lung fields.

Impression: Moderate pleural fluid bilateral

Nutrition

The diet of the patients requires no potassium containing foods such as

bananas, nuts, orange, potatoes and ect., because based on the laboratory
result the potassium level of the patients is above the normal range. High level of
potassium in the body can cause hyperkalemia and the patient might experience
abnormal heart rhythms.
Other factors of the diet that can influence the development of chronic
renal insufficiency include: content and composition of the lipids and proteins,
consumption of sodium and phosphorus, total consumption of calories, acidic
nature of the diet. The diet therapy may influence progression of renal failure.
Protein restriction may minimize spontaneous, progressive renal damage in
patients with CRF by modifying renal hemodynamics or compensatory renal
growth. Because proteinaceous foods are a major dietary source of phosphorus,
dietary protein restriction is associated with a simultaneous reduction in
phosphorus intake with potential amelioration of renal secondary
hyperparathyroidism. The restriction of sodium must be moderated because
excessive or rapid sodium restriction can cause decrease of the extracellular
volume and systemic dehydration and hypotension. Consumption of acidic diet is
totally restricted.

Medical Management

Chronic renal failure can be treated by conservative management of renal

insufficiency and by renal replacement therapy with dialysis or transplantation.
Conservative treatment consists of measures to prevent or retard deterioration in
remaining renal function and to assist the body in compensating for the existing
impairment. Interventions that have been shown to significantly retard the
progression of chronic renal insufficiency include dietary protein restriction and
blood pressure normalization. Various interventions are used to compensate for
reduced renal function and correct the resulting anemia, hypocalcemia, and
acidosis. These interventions often are used in conjunction with dialysis therapy
for patients with end-stage renal disease (ESRD).
Prognosis

The survival rate of people which chronic renal failure has improved with the
advent and improvement of dialysis and transplantation. At 1 year after dialysis
begins the survival rate is about 79% after 5 years, the rate decrease to 33%.

In this case, the patient refuse the dialysis the patient will be at risk of getting
more complicated in her health status due to her sickness; therefore the
prognosis is poor because the patient having Chronic Renal Failure can be cure
by means of dialysis.
Recommendation

Our health relies on what lifestyle we have. We would like to recommend

to the patient to take all medications as directed by the doctor and see the health
care provider as recommended for follow- up and proper monitoring of their
health status. The patient should also follow the recommended diet prescribe by
the doctor and of the dietitians. As much as possible she should follow as what
the doctor’s order to undergone dialysis.
For the family they should always monitor the health status of the patient
as will as the proper intake of medication and the diet as will. The family should
also support not only for financial but also in terms of emotional aspects. And for
the health of other member of the family they should also practice the proper
healthy lifestyle. To maintain good health, take foods that are nutritious, but be
sure that it is in moderation.
To our fellow students, we must start a healthy lifestyle now; by simply
choose those nutritious foods. As much as possible we must avoid drinking, and
eating those acidic and salty foods. We must consume low fats and sugar
containing foods in order to maintain good health. We must take care our kidney
as early as possible to have a healthy body in later stage of our life. “It is said
that prevention is better than cure.”

Secondary Hypertension-Hypertension commonly is an early

manifestation of chronic renal failure. The mechanisms that produce
hypertension in ESRD are multifactorial; they include an increase vascular
volume, elevation of peripheral vascular resistance, and decreased level of renal
vasodilator prostaglandins.

Only 5% to 10% of hypertensive cases are classified as secondary

hypertension. Secondary hypertension tends to be seen in persons younger than
30 and older than 50 years of age. Among the most common causes of
secondary hypertension are kidney diseases. Most chronic kidney disease
results in decreased urine formation, retention of salt and water, and
hypertension. Hypertension also common among persons with chronic
pyelonephritis, polycystic kidney disease, diabetic nephropathy and end- stage
renal disease, regardless of cause.