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Anemia 2 Chronic Kidney Disease 2

Hypertensive Nephroschlerosis

North Valley College Foundation Inc.


Lanao, Kidapawan City

A CASE STUDY ON
ANEMIA 2 CHRONIC KIDNEY DISEASE 2
HYPERTENSIVE NEPHROSCHLEROSIS

Class Graduates of 2011

February 2010
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

ACKNOWLEDGENMENT

We wish to acknowledge the following for having been part of this wonderful experience:
First and foremost, to our Almighty God who in His wisdom leads us in the right path
and destination.

To the family, for their hospitality and cooperation during our initial assessment and
gathering of data in the hospital. Truly, they have inspired us and paved us a way in realizing
that life is very precious and each second should count.

To the doctors and staff of Southern Philippines Medical Center, for allowing their
institution as one of the training areas for our Related Learning Experience.

To our Clinical Instructor, Ms. Cherry M. Bartolaba, R.N,MAN. who shared her knowledge,
experience and expertise in dealing with our Ward exposure in Southern Philippines Medical
Center. More importantly, for showing us the real value of commitment and guiding us for
this profession.

The North Valley College Foundation Incorporated for allowing us this learning experience
which we will treasure always and bring wherever road will take us.
In to our families and friends, who serves as our inspiration in all endeavors, for their
unconditional support and encouragement.
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

INTRODUCTION

Health is the general condition of a person in all aspects. It is also a level of


functional and/or metabolic efficiency of an organism, often implicitly human. According to
WHO (World Health Organization) Health was defined as being "a state of complete
physical, mental, and social well-being and not merely the absence of disease or infirmity.
When most people think about health they conjure up images that are related to
physical health. Physical health is anything that has to do with our bodies as a physical entity.
It has been the basis for active living campaigns and the many eat right fads that have swept
our country. With so much information about physical health it is often difficult to determine
what is current and relevant. Physical health and wellness is often regarded or measured
through ones own physical strength, endurance and flexibility. Physical strength, per se, may
mean the cardiovascular and muscular strength being possessed by an individual.
Our case is about Anemia secondary to Chronic Kidney Failure secondary to
Hypertensive Nephroschlerosis. Mr. WBC; our subject in this case is a 45 year-old who is
presently residing at Phase 20 Catalonan, Pequeno, Davao City.

Anemia is the decrease in the normal number of red blood cells, a decrease in
hematocrit or a decrease in the normal quantity of hemoglobin in the blood. It can also
include the decrease in oxygen-binding ability of each hemoglobin molecule because of the
deformity or lack in the development as in other hemoglobin deficiency.

Because hemoglobin (found inside RBCs) normally carries oxygen from the lungs to
the tissues, anemia leads to hypoxia (lack of oxygen) in organs. Because all human cells
depend on oxygen for survival, varying degrees of anemia can have a wide range of clinical
consequences.

OBJECTIVES OF THE STUDY


Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

General Objectives:

To provide information and knowledge about the nature of disease and also to comply with
the requirements of the Nursing Care Management 103 of the BSN.

Specific Objectives:

1. Choose a client to be the subject of he study;


2. To develop a trusting relationship with the client and his family through establishing
rapport;
3. To elaborate the personal data, physical assessment, the past and present history data
of the patient;
4. To define the terminologies utilized in the case;
5. To site and discuss the anatomy and physiology of the Circulatory system, kidney and
blood components;
6. To trace Pathophysiology of Anemia and its possible complications;
7. To evaluate laboratory exams and prognosis of the patient;
8. To identify and present the medication given to the patient related to his illness;
9. To formulate a nursing care plan that could effectively alleviate the patients
condition;
10. To formulate a realistic prognosis based on the information gathered.

TABLE OF CONTENTS
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

Title Page
Acknowledgement i
Introduction.. ii
Objectives. iii
Table of Contents. iv
Patients Personal Data 1
General Assessment.. 2
o Patients Personal Data
o Past Medical History
o Present Medical History
o Familial Tendency
o General Appearance on First Sight
Definition of Terms.. 6
Anatomy and Physiology. 7
Pathophysiology 18
Medical Management.. 19
Laboratory Results.. 21
Drug Study 25
Nursing Care Plans.. 30
Discharge Planning.. 39
Prognosis 42
Anemia 2 Chronic Kidney Disease 2
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PERSONAL DATA

Patients Name : W.B.C.


Age : 45 yrs.old
Sex : Male
Date of Birth : July 9, 1964
Place of Birth : ICAGOS
Address : Phase 20 Catalonan, Pequeno, Davao City
Name of Father : T.B.C.
Name of Mother : P.B.C.
Religion : Roman Catholic
Name of Hospital : Davao Medical Center
Department : Internal Medicine
Ward : Family Medicine Ward
Case Number : 2010005635
Date of Admission : February 6, 2010
Chief Complaint : Body Weakness (Arthritis)
Admitting Diagnosis : Gouty Arthritis in Flare
Attending Physician : Dr. Emerson R. Taghoy
Final Diagnosis Anemia 2 Chronic Kidney Disease
2 Hypertensive Nephrosclerosis

GENERAL ASSESSMENT
Anemia 2 Chronic Kidney Disease 2
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I. PATIENTS PERSONAL DATA

Patients Name : WBC


Address : Phase 20 Catalonan, Pequeno, Davao City
Date of Admission : February 6, 2010
Chief Complaint : Body Weakness (Arthritis)
Final Diagnosis : Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis
Attending Physician : Dr. Emerson R. Taghoy

II. PAST MEDICAL HISTORY


As verbalized by the patients wife, the patient was admitted many times
in Southern Philippines Medical Center due to intolerable joint pains, fatigability,
paleness and series of shortness of breath for the past several months.

III. PRESENT MEDICAL HISTORY


Mr. WBC, male, 45 years of age admitted to Southern Philippines Medical
Center at Internal Medicine Department last February 6, 2010, was suffering from
joint pains on upper and lower extremities (hands and feet) and generalized
weakness prior to his admission. He is also experiencing decreased urine output.
Persistence of his condition prompted this admission.

IV. FAMILIAL TENDENCY


Mr. WBC stated that his father is hypertensive and his grandmother had
chronic renal failure.

V. GENERAL APPREARANCE AT FIRST SIGHT


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We received patient sitting on wheelchair awake without IVF wearing


loose gray Tee shirt and shorts. The patient appeared to be pale all over the body
and was irritable due to pain noted on his upper and lower extremities. Swollen
knees and elbows and with decreased range of motion noted. The patient was
oriented to person, place and time. He also had signs of hair loss on his head. He
was noted uneasy and uncomfortable because of dizziness.

SENSE OF SIGHT
The patient cant identify objects at approximately 3 meters farther, but is
oriented to familiar faces. The patient was observed to be dependent on his
eyeglasses when reading newspapers or any reading materials.

SENSE OF HEARING
Patient has poor hearing competence as observed during the interview. He
cant hear some questions and simple instructions easily even at close distance. He
emphasized that louder voice than normal could help him hear clearly.

SENSE OF SMELL
MR. WBCs sense of smell was not impaired. He can well identify alcohol
from cologne upon assessment. Both nostrils are patent for airway. No obstruction
and discharges were noted.

SENSE OF TASTE
Patients sense of taste was not altered, as verbalized by him. He can identify
and differentiate bitter, sour, salty, and sweet foods.

SENSE OF TOUCH
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The patients skin appears to be pale and relatively dry. His skin was cold and
clammy to touch and has poor skin turgor (4-6 seconds). Uncut nails on fingers and
toes noted. No pertinent scar noted from the face down to arms.

CARDIOVASCULAR
During our span of care his Blood Pressure ranges from 90/70- 130/90
mmHg.The capillary refill time is 3-5 seconds. He has a palpable pounding pulse and
a cardiac rate ranging from 75-89 beats per minute.

RESPIRATORY
During our span of care, patient is experiencing shortness of breath
occasionally as evidenced by even deep respirations with great effort and with a
respiratory rate ranging from 10 - 25 cycles per minute. The doctor ordered O2 as
PRN, no crackles, no rales and no other unusualities was noted.

ELIMINATION PATTERN
As the patient verbalized, he usually urinates 6-8 times a day to a scanty
amount of yellow colored urine, at home. While compared in the hospital, he urinates
three times a day with lighter yellow colored urine as recorded in our 8 hours span of
care. He defecates 1-2 times a day with formed stool at home and defecates once a
day at the hospital.

SLEEPING PATTERN
As the patient verbalized, he tends to have 4-5 hours of sleep a day but having
a nocturnal awakening at some time due to small and frequent urination. Since sleep
patterns also vary on aging process. In the hospital, he experiences difficulty sleeping
due to warm environment and poor ventilation.

EXTREMITIES
Patient range of motion was decreased and altered due to joint pain and
inflammation on both upper (elbows) and lower (knees) extremities. Dry skin noted
Anemia 2 Chronic Kidney Disease 2
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with no lesions. He had even hair distribution on his extremities and pallor on the
upper and lower extremities specifically on his hands, arms and legs. Patient had a
cold clammy skin upon assessment when touched on his hand.

NUTRITIONAL PATTERN
As the patient verbalized, he eats three times a day and he loves to eat meat
and fish (anchovy and anchovy paste; dried fish ), he also eats canned goods for a
quick meal viand. He often drinks liquor three times a week and can consume 1-3
bottles every time he does. Choice s of alcoholic drinks are usually Tanduay, San
Miguel Beer or Red Horse with his kumpadres , as verbalized by the patient. He
often prepares cooked internal organs or fish dipped in vinegar as pulutan.
Upon admission, the patient was ordered on a Low salt, low fat diet and an
increase on oral fluid intake. His mother and wife always brings his meals, usually
vegetable dishes such as dining-ding and soup.

DEFINITION OF TERMS
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Acute uric acid nephropathy - is a rapidly worsening (decreasing) kidney function (renal
insufficiency) that is caused by high levels of uric acid in
the urine (hyperuricosuria).
Albumin - refers generally to any protein that is water soluble, which is moderately soluble
in concentrated salt solutions, and experiences heat coagulation(protein
denaturation). Substances containing albumin, such as egg white, are called
albuminoids.
Anemia - is a decrease in normal number of red blood cells (RBCs) or less than the normal
quantity of hemoglobin in the blood
Creatinine - is a spontaneously formed cyclic derivative of creatine. Creatinine is chiefly
filtered out of the blood by the kidneys (glomerular filtration and proximal
tubular secretion).
Erythropoiesis - is the process by which red blood cells (erythrocytes) are produced. It is
stimulated by decreased O2 delivery to the kidneys, which then secrete the
hormone erythropoietin
Hypertensive nephropathy - (or "hypertensive nephrosclerosis", or "Hypertensive renal
disease") is a medical condition referring to damage to the kidney due to
chronic high blood pressure.
Hyperuricemia - is a level of uric acid in the blood that is abnormally high. In humans, the
upper end of the normal range is 360 mol/L (6 mg/dL) for women and
400 mol/L (6.8 mg/dL) for men.
Purine - is a heterocyclic aromatic organic compound, consisting of apyrimidine ring fused
to an imidazole ring. Purines, including substituted purines and
their tautomers, are the most widely distributed kind of nitrogen-containing
heterocycle in nature.

ANATOMY AND PHYSIOLOGY

Blood
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Blood is one of the connective tissues. As a connective tissue, it consists of cells and
cell fragments (formed elements) suspended in an intercellular matrix (plasma). Blood is the
only liquid tissue in the body that measures about 5 liters in the adult human and accounts for
8 percent of the body weight.

The body consists of metabolically active cells that need a continuous supply of
nutrients and oxygen. Metabolic waste products need to be removed from the cells to
maintain a stable cellular environment. Blood is the primary transport medium that is
responsible for meeting these cellular demands.

Blood cells are formed in the bone marrow, the soft, spongy center of bones. New
(immature) blood cells are called blasts. Some blasts stay in the marrow to mature. Some
travel to other parts of the body to mature.

The activities of the blood may be categorized as transportation, regulation, and


protection.
These functional categories overlap and interact as the blood carries out its role in providing
suitable conditions for celluar functions.
The transport functions include:
carrying oxygen and nutrients to the cells.
transporting carbon dioxide and nitrogenous wastes from the tissues to the lungs
and kidneys where these wastes can be removed from the body.
Carrying hormones from the endocrine glands to the target tissues.

The regulation functions include:


Helping regulate body temperature by removing heat from active areas, such as
skeletal muscles, and transporting it to other regions or to the skin where it can
be dissipated.
Playing a significant role in fluid and electrolyte balance because the salts and
plasma proteins contribute to the osmotic pressure.
Functioning in pH regulation through the action of buffers in the blood.
Anemia 2 Chronic Kidney Disease 2
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The protection functions include:


Preventing fluid loss through hemorrhage
when blood vessels are damaged due to its
clotting mechanisms.
Helping (phagocytic white-blood cells) to
protect the body against microorganisms
that cause disease by engulfing and
destroying the agent.
Protecting (antibodies in the plasma)
protect against disease by their reactions
with offending agents.

Composition of blood

When a sample of blood is spun in a centrifuge, the cells and cell fragments are
separated from the liquid intercellular matrix. Because the formed elements are heavier than
the liquid matrix, they are packed in the bottom of the tube by the centrifugal force. The light
yellow colored liquid on the top is the plasma, which accounts for about 55 percent of the
blood volume and red blood cells is called the hematocrit, or packed cell volume (PCV). The
white blood cells and platelets form a thin white layer, called the buffy coat, between
plasma and red blood cells.

Plasma
The watery fluid portion of blood (90 percent
water) in which the corpuscular elements are
suspended. It transports nutrients as well as wastes
throughout the body. Various compounds, including
proteins, electrolytes, carbohydrates, minerals, and fats,
are dissolved in it.
Anemia 2 Chronic Kidney Disease 2
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Formed Elements
The formed elements are cells and cell fragments suspended in the plasma. The three
classes of formed elements are the erythrocytes (red blood cells), leukocytes (white blood
cells), and the thrombocytes (platelets).

Erythrocytes (red blood cells)


Erythrocytes, or red blood cells, are the most numerous of the formed elements.
Erythrocytes are tiny biconcave disks, thin in the middle and thicker around the periphery.
The shape provides a combination of flexibility for moving through tiny capillaries with a
maximum surface area for the diffusion of gases. The primary function of erythrocytes is to
transport oxygen and, to a lesser extent, carbon dioxide.

Leukocytes (white blood cells)


Leukocytes or white blood cells are generally larger than erythrocytes, but they are
fewer in number. Even though they are considered to be blood cells, leukocytes do most of
their work in the tissues. They use the blood as a transport medium. Some are phagocytic,
others produce antibodies, some secrete histamine and, heparin, and others neutralize
histamine. Leukocytes are able to move through the capillary walls into the tissue spaces, a
process called diapedesis.In the tissue spaces they provide a defense against organisms
that cause diseaseand either promote or inhibit inflammatory responses.
There are two main groups of leukocytes in the blood. The cells that develop granules
in the cytoplasm are called granulocytes and those that do not have granules are called
agranulocytes. Neutrophils, eosinophils, and basophils are granulocytes. Monocytes and
lymphocytes are agranulocytes.
Neutrophils, the most numerous leukocytes, are phagocytic and have light-colored granules.
Eosinophils have granules and help counteract the effects of histamine. Basophils secrete
histomine and heparin and have blue granules. In the tissues, they are called mastcells.
Lymphocytes are agranulocytes that have a special role in immune processes. Some attack
bacteria directly; others produce antibodies.

Thrombocytes (platelets)
Thrombocytes, or platelets, are not complete cells, but are small fragments of very
large cells called megakaryocytes. Megakaryocytes develop from hemocytoblasts in the red
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bone marrow. Thrombocytes become sticky and clump together to form platelet plugs that
close breaks and tears in blood vessels. They also initiate the formation of blood clots.

Blood Cell Lineage:


The production of formed elements, or blood cells, is called hemopoiesis. Before
birth, hemopoiesis occurs primarily in the liver and spleen, but some cells develop in the
thymus, lymph nodes, and red bone marrow. After birth, most production is limited to red
bone marrow in specific regions, but some white blood cells are produced in lymphoid tissue.
All types of formed elements develop from a single cell type stem cell
(pleuripotential cells or hemocytoblasts). Seven different cell lines, each controlled by a
specific growth factor, develop from the hemocytoblast. When a stem cell divides, one of the
daughters remains a stem cell and the other becomes a precursor cell, either a lymphoid
cell or a myeloid cell. These cells continue to mature into various blood cells.
A leukemia can develop at any point in cell differentiation. The illustration below shows the
development of the formed elements of the blood.
Blood-related cancers, or leukemias, have been shown to arise from a rare subset of
cells that escape normal regulation and drive the formation and growth of the tumor. The
finding that these so-called cancer stem cells, or leukemic stem cells (LSC), can be purified
away from the other cells in the tumor allows their precise analysis to identify candidate
molecules and regulatory pathways that play a role in progression, maintenance, and
spreading of leukemias. The analyses of the other, numerically dominant, cells in the tumor,
while also interesting, do not directly interrogate these key properties of malignancies.
Mouse models of human myeloproliferative disorder and acute myelogenous leukemia have
highlighted the remarkable conservation of disease mechanisms between both species. They
can now be used to identify the LSC for each type of human leukemia and understand how
they escape normal regulation and become malignant. Given the clinical importance of LSC
identification, the insights gained through these approaches will quickly translate into clinical
applications and lead to improved treatments for human leukemias.

URINARY SYSTEM
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Our
body is
like a

machine . Machine needs oil or gasoline to work. Our body needs food in order to carry out
its activities. Once the food has reached the body systems, they are quickly used for energy.
In the process, wastes materials are produced which need to be removed from the body. The
solid waste material comes out through the anus, while the fluid material is eliminated
through the urinary system.

The Urinary System and Its Major Parts

Kidneys

The kidneys are two brownish, bean shaped organs about the size of a fist, they weigh
about 5 ounces. They are located in the upper right and left back part of the abdominal cavity.
Each kidney contains about 1,200,000 microscopic filters called nephrons. Nephrons are
smaller than the smaller dots.

The main function or the kidneys are to maintain the water balance and to eliminate
waste materials from the blood.

Ureters

The left and the right ureters are long muscular tubes. They are about 12 inches long
with a diameter 2 to 3 millimeters.
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The ureters connect pelvis of each kidney to urinary bladder. They carry urine from
each kidney to the urinary bladder.

The Urinary Bladder

The urinary bladder is a muscular sac that holds urine. It is located in front the pelvis
and behind the pubis. As the bladder fills walls stretch signaling the desire to urinate.

The Urethra

The urethra is a muscular tube which carries urine from the bladder to the outside part
of the body. In the female, it is a one inch long from the bladder to the cleft of the labia. In
the male, it is several inches long from the prostate gland to the penis. When one is about to
urinate, a value in the urethra relaxes to allow the urine to flow out.

The Urinary System Cleans the Blood

Waste Products
During normal activity of the body, waste product are formed. The chief waste of the
body are carbon dioxide, water, urea and salts. Carbon dioxide is eliminated through the
lungs while water, urea and salts are eliminated through the urine. Urea is a product resulting
from the breakdown of protein foods and of protoplasm. It is excreted mainly but the
kidneys.

Urinary Systems Mechanism

Glomerulus

Each nephron is composed of a glomerulus. The glomerulus is surrounded by hollow


capsule known as Bowmans Capsule. The capillaries in the glomerulus filters the waste
materials of the blood except protein and the cells.
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Filtered Fluid

The filtered fluid enters the bowmans capsule, where it flow down through its
twisted tubes. The walls of the tubes absorb back in to the blood the needed water and blood
chemicals.

Pathway of Unwanted Chemicals

Unwanted chemicals are discharged. The unwanted chemicals are the waste products.
They come out in the form of urine. The urine passes into the ureter and on to the urinary
bladder. And the urethra which releases it to the outside of the body. Urine gives valuable
clues to the body. Sugar in the urine is an indication of diabetes. Albumen may signify that
the kidneys are not functioning properly.

CIRCULATORY SYSTEM
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The human circulatory system. Red indicates oxygenated blood, blue indicates
deoxygenated.

The circulatory system is an organ system that passes nutrients (such asamino
acids and electrolytes), gases, hormones, blood cells, etc. to and fromcells in the body to help
fight diseases and help stabilize body temperature andpH to maintain homeostasis.

This system may be seen strictly as a blood distribution network, but some consider
the circulatory system as composed of the cardiovascular system, which distributes blood,
[1]
and the lymphatic system,[2] which distributeslymph. While humans, as well as
other vertebrates, have a closed cardiovascular system (meaning that the blood never leaves
the network ofarteries, veins and capillaries), some invertebrate groups have an open
cardiovascular system. The most primitive animal phyla lack circulatory systems. The
lymphatic system, on the other hand, is an open system.

Two types of fluids move through the circulatory system: blood and lymph. The
blood, heart, and blood vessels form the cardiovascular system. The lymph, lymph nodes,
and lymph vessels form the lymphatic system. The cardiovascular system and the lymphatic
system collectively make up the circulatory system.

Human Cardiovascular System


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The main components of the human cardiovascular system are the heart and the blood
vessels.[3] It includes: the pulmonary circulation, a "loop" through the lungs where blood is
oxygenated; and the systemic circulation, a "loop" through the rest of the body to
provide oxygenated blood. An average adult contains five to six quarts (roughly 4.7 to 5.7
liters) of blood, which consists of plasma, red blood cells, white blood cells, and platelets.
Also, the digestive system works with the circulatory system to provide the nutrients the
system needs to keep the heart pumping.

Pulmonary circulation
The Pulmonary circulation is the portion of the cardiovascular system which
transports oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated
blood back to the heart.

Oxygen deprived blood from the vena cava enters the right atrium of the heart and flows
through the tricuspid valve into the right ventricle, from which it is pumped through
the pulmonary semilunar valve into the pulmonary arteries which go to the lungs. Pulmonary
veins return the now oxygen-rich blood to the heart, where it enters the left atrium before
flowing through the mitral valve into the left ventricle. Then, oxygen-rich blood from the left
ventricle is pumped out via the aorta, and on to the rest of the body.

Systemic circulation
Systemic circulation is the portion of the cardiovascular system which transports oxygenated
blood away from the heart, to the rest of the body, and returns oxygen-depleted blood back to
the heart. Systemic circulation is, distance-wise, much longer than pulmonary circulation,
transporting blood to every part of the body.

Coronary circulation
The coronary circulatory system provides a blood supply to the heart. As it provides
oxygenated blood to the heart, it is by definition a part of the systemic circulatory system.

Heart
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View from the front, which means the right side of the heart is on the left of the diagram (and
vice-versa)
Main article: heart
The heart pumps oxygenated blood to the body and deoxygenated blood to the lungs. In the
human heart there is one atrium and oneventricle for each circulation, and with both a
systemic and a pulmonary circulation there are four chambers in total: left atrium, left
ventricle, right atrium and right ventricle. The right atrium is the upper chamber of the right
side of the heart. The blood that is returned to the right atrium is deoxygenated (poor in
oxygen) and passed into the right ventricle to be pumped through the pulmonary artery to the
lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly
oxygenated blood from the lungs as well as the pulmonary vein which is passed into the
strong left ventricle to be pumped through the aorta to the different organs of the body.

Closed cardiovascular system


The cardiovascular systems of humans are closed, meaning that the blood never leaves the
network of blood vessels. In contrast, oxygen and nutrients diffuse across the blood vessel
layers and entersinterstitial fluid, which carries oxygen and nutrients to the target cells, and
carbon dioxide and wastes in the opposite direction. The other component of the circulatory
system, the lymphatic system, is not closed. The heart is located in the center of the body
between the two lungs. The reason that the heart beat is felt on the left side is because the left
ventricle is pumping harder.

PATHOPHYSIOLOGY

PREDISPOSING FACTORS PRECIPITATING FACTORS

Age (45 y.o.) Lifestyle


Genetic Diet: purine intake
Long-term alcohol
consumption
Medical Condition
( hypertension)

Monosodium urate
Hyperurecemia
crystal
Blood circulation in
disposition
blood Kidneys
throughout the body
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Joints

Monosodium urate
precipitates at the
periphery of the body
Perfusion in kidneys

Arthritis
Blood flow to
kidneys

Disposition on renal
interstitial tissues

Impaired urine flow


(Water retention)

Chronic Kidney
Disease

Remaining nephrons RBC production


undergo vasodilation
of preglomerular
arterioles to Oxygen carrying
compensate capacity of the blood
(hgb)

Renal blood flow and


glomerular filtration S/Sx:
Hypoxia
Pallor (Observed
in the extremities)
Plasma creatinine value Fatigue
Poor concentration
Dizziness
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ANEMIA

If treated: If untreated:
Prevent mental
further function
complication Heart &
s & infection kidney
oxygen in problems
the blood Death

PATHOPHYSIOLOGY

Narrative

With regards to our patients case, the following are the predisposing factors which
contribute to his condition. These include: his age (45 y.o.) and genetic or familial history.
Studies show that aside from hypertension, age is an independent major predictor of chronic
kidney disease. Other than that, precipitating factors also contribute to increase the risks of
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this said condition such as lifestyle, diet high in purines, weight, a long-term alcohol
consumption and medical condition (hypertension).

Since the patients diet is high in purine, these purine- rich foods break down into uric
acid. Uric acid levels in the blood and other parts of the body can become too high or what
we call hyperurecemia. These urate crystals travel all through out the system of our body.
Once it reaches the kidneys, it will accumulate and build up into it. Thus, it alters its function.
There will be a decrease in blood flow and perfusion that mazy lead to Chronic Kidney
Disease. As an attempt to compensate for the loss of renal function, the remaining nephrons
undergo vasodilation of the preglomerular arterioles and experience an increase in renal
blood flow and glomerular filtration. The result is glomerular hypertension. These
mechanisms are not mutuatlly exclusive, and they may operate simultaneously in the
kidneys.
Furthermore, a decrease in the function of the kidneys may also decrease the
production of red blood cells which carries oxygen into the blood (hemoglobin). When it
happens, hypoxia occurs. Then, some signs and symptoms may also be observed in the client
such as pallor, fatigue, poor concentration and dizziness. Thus, all these mechanism may
result to a disease called anemia.

MEDICAL MANAGEMENT

Date PROGRESS NOTES


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2/6/10 Please admit to Med Level II


Low salt/ low fat Diet
LABS
CBC + Plt
U/A
Creatinine
Na
K
Uric Acid
CXR
ECG- 12 lead
X-ray APL Bilateral
Medications:
Colchicine 100mg 1 tab TID
Celecoxib 200 mg 1 tab TID
IVF PNSS @ 120 cc/
Monitor VS
EMERSON R. TAGHOY, MD
2/7/10 Dx: on the KUB
SGPT
2:30 am Blood Typing
To secure 2 units Packed RBC of patients blood type
Transfuse after proper X-matching
Meds
NaHCO3 1 tab TID
CaCO3 1 tab TID
EMERSON R. TAGHOY, MD
2/8/10 Fever
Joint pain
10 am UTZ of the KUB-P (2/10/10 ; 1:30 pm) Urinalysis
Transfuse available unit of PRBC after proper cross
matching
Shift colchicines 100mg 1 tab OD
Continue other medications
Increase oral fluid intake
Refer
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

Herceds

Please facilitate UTZ in am c/o Dr. Moncoda


If cant comply with 2 units PRBC , BT MAY DISCHARGE AMOUNT
PROVIDED @ bleeding manifestations
4 pm
2/9/10 Dx: FR UTZ of KUB THIS - 1:30 pm
Follow-up Official X-ray Result
Post BT 1 unit
Continue PRESENT MEDS
OFI
NOTE ANY UNUSUALITIES
REFER EMERSON R. TAGHOY,
MD
2/10/10 FOLLOW-UP OFFICIAL UTZ KUB RESULT (Tom 10:00 am)
For U/S
Continue Present meds
Refer
EMERSON R. TAGHOY, MD
2/11/10 FOLLOW-UP OFFICIAL UTZ KUB RESULT tomorrow
For Schedule of Knee APL R XRay
Refer
EMERSON R. TAGHOY, MD
2/12/10 Home Medications
FeSO4 1 tab TID for 1month
Alloperinol 100mg 1 tab OD
Celecoxib 200mg 1tab BID for pain
OPD follow-up after a week
DONE!
EMERSON R. TAGHOY, MD

LABORATORY

PID: 2148108 Lab.No.:10018137 Location: Med- ER Date: 2/6/10


Name: WBC Age: 45 yrs.old Sex: Male Clinician: Taghoy, Emerson M.D.

TF-ST Result Normal Ranges Significance


Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

IPD Hematology
CBC + PLT
Hemoglobin 81.0 L(low) 135-175g/ L A low hemoglobin count can also
be caused by an abnormality or
disease. In these situations, a low
hemoglobin count is referred to as
anemia
Hematocrit 0. 24 L(low) 0. 40- 0. 52 A low hematocrit is referred to as
being anemic
RBC Count 3. 02 L(low) 4. 20- 6. 10 x 10^ Anemia is the condition of having
6/uL less than the normal number of red
blood cells or less than the normal
quantity of hemoglobin in the
blood. The oxygen-carrying
capacity of the blood is, therefore,
decreased.
WBC Count 6. 69 5.0- 10. 0 x 10^ 3/uL No infection.
Differential
Count
Neutrophil 64 55- 75%
Lymphocytes 19 L(low) 20- 35% Lymphocytes help protect your
body from infection. Low numbers
of lymphocytes can increase your
risk for infection.
Borderline for impending infection.
Monocytes 9 2- 10%
Eosinophils 8 1- 6%
Basophils 0 0- 1%
Platelet Count 466 H 150- 400x 10^ 3/uL May have a tendency to bleed due
to the lack of stickiness of the
platelets; in others, the platelets
retain their stickiness but, because
they are increased in number, tend
to stick to each other, forming
clumps that can block a blood
vessel and cause damage, including
death (thromboembolism).
MCH 26. 8 25. 70- 32. 20pg
MCHC 33. 6 32. 30- 36. 50g/ dL
ER
Glucose- RBS 5.5 3. 90- 6. 10
Creatinine 299. 30 53.00- 115.00 mmol/ Increased creatinine levels in the
L (High) blood suggest diseases or
conditions that affect kidney
function.
Sodium 138. 00 136- 155.00 mmol/ L
Potassium 4.4 3.5- 5.5 mmol/ L
Uric Acid 0. 85 0.24- 0.42 mmol/ L Increased concentrations of uric
(High) acid can cause crystals to form in
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

the joints, which leads to the joint


inflammation and pain
characteristic of gout. Uric acid can
also form crystals or kidney stones
that can damage the kidneys.

Edmundo V. Visitacion, MD, FFSP


APCP

LAB NO: 1395 Date: 2/6/10


Name: WBC Age: 45 Yrs. Old Sex: Male

BLOOD TYPING

Specimen Blood Type


Blood O +

Abelo
Physician

LAB NO: 4504 Date: 2/6/10


Name: WBC Age: 45 Yrs. Old Sex: Male
CLINICAL MICROSCOPY
Specimen: URINE
A. Physical Examination
Color Yellow
Appearance Slightly Cloudy
Reaction 6.0
Specific Gravity 1.015
Albumin (+)
Sugar Negative
B. Microscopic Exam
Epithelial Cells +
Squamous
Renal
Pus Cells 12-17/ hpf
RBC 1-2/ hpf
Mucus Threads +
Bacteria
Yeast Cells
Oil Globules
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

Spermatozoa

ROENTOLOGICAL REPORT
Name: WBC Dept: Internal Medicine Area: Charity Ward Date: 2/6/10
Age: 45 Yrs. Old Sex: Male
Chest PA (ADULT)
Findings:
The lungs are clear. Tracheal air column are at the midline. The heart is not enlarged. Both
hemidiaphragms and costophrenic sulci are intact. The rest of the structures are unremarkable.

NO SIGNIFICANT CHEST FINDINGS


Impressions/ Remark
Repeat study with proper factor and positioning

LAB NO: 4222 Date: 2/8/10


Name: WBC Age: 45 Yrs. Old Sex: Male
CLINICAL MICROSCOPY
Specimen: URINE
A. Physical Examination
Color Yellow
Appearance Clear
Reaction 5.0
Specific Gravity 1.020
Albumin (+)
Sugar Negative
B. Microscopic Exam
Epithelial Cells +
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

Squamous
Renal
Pus Cells 6-10 / hpf
RBC 0-2 / hpf
Mucus Threads
Bacteria
Yeast Cells
Oil Globules
Spermatozoa

ULTRASOUND
Name: WBC Age: 45 Yrs. Old Sex: Male Date: 2/10/10
RESULT FINDINGS
Length Width Thickness(cm) Cortical Thickness (cm)
Right Kidney 9.56 4.31 5.33 1.41
Left Kidney 10.50 4.39 4.63 1.54
Impressions/ Remark
Bilateral Nephroschlerosis
Sonographically Normal Urinary Bladder
Earnest L. Pedregosa, MD Maria Theresa Sanchez, MD
Medical Officer IV Medical Officer IV

PROGNOSIS

CRITERIA POOR GOOD JUSTIFICATION


1. Duration of illness It is poor for the reason that the
patient had experience gouty arthritis
at his 40s until present. He still has to
be observed for further treatment.

2. Onset of illness Onset of signs and symptoms happens


when its cold and had been sent into
the hospital for prompt medical
attention.
3. Precipitating Factor Food preference of the patient is high
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

in uric acid and salt, which increases


the risks for gouty arthritis.
4. Willingness to take The patient is willing to take
medication medications provided by the
institution.
5. Age (45 y.o.) People ages 40 and above are more
high risks for gouty arthritis. Body
functioning and body repair
mechanism deteriorates on aging.
6. Environment The patients access to healthcare had
been taken for granted, even if they
live in urban area, for the reason of
financial constraints.
7. Family support His family had been very supportive
throughout the period of his
hospitalization.

Computation:
Prognosis
Formula=_______________X 100
Criteria
Solution:
a.) POOR b.) GOOD
4 3
= --- X 100 = --- X 100
7 7
= 0.5714 x 100 = 0.4285
= 57.1428 = 42.8571

SUMMARY
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

The general prognosis of our patient is poor as shown in the table above. Considering that
there are several significant factors contributing to his illness. Prompt identification of factors
affecting high risk requires prompt intervention in order to enhance clients quality of life.

DISCHARGE PLANNING
Medications

Instruct patient to comply with the treatment regimen as prescribed.


: Drugs should be taken as prescribed in order to prevent resistance to the susceptible
disease.

Motivate the patient and initiate family members to always seek medical advise.
: This facilitates their understanding towards health and wont rely to other medicines
that could not help the status of the patient.

Emphasize the importance of taking medications according to the prescribed schedule


and dosage.
: To ensure that the patient would comply with the regimen treatment.
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

Environment and Exercise


Provide good ventilation.
: To promote comfort and relaxing environment

Explain environmental factors that may worsen his condition and discuss possible
precipitating factors
: This prevents recurrence or exacerbation of the patients condition.

Provide rest periods to facilitate comfort, sleep and relaxation.


: A quiet environment, a darkened room and a disconnected phone are all measures
geared toward facilitating rest.

Stress management.
: Stress management can be considered a cornerstone to a healthy lifestyle.

Treatment

Encourage increase Oral Fluid Intake.


: To dilute urine and promote normal and frequent urination.

Instruct the patient to take all prescribed medicines.


: Facilitates faster recovery and prevents from further complication.

Teach the patient to monitor own input and output.


: Enables the patient to notice some abnormalities that he could inform the physician.

Actual information about the illness.


: To reduce anxiety and so that they will know when to consult the physician.
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

Hygiene and Health Teachings

Encourage daily bathing.


: Promote comfort and cleanliness.

Instruct proper care of the affected area.


: To prevent further complication.

Teach patient with proper hygiene.


: This decreases risk of infection and promotes maintenance and integrity of skin and
teeth.

Reporting of unusual symptoms to a health professional.


: This initiates early treatment.

Outpatient Orders

Remind patient for a follow-up check-up to the physician.


: Enables the physician to evaluate the clients condition after the hospitalization.

Instruct the patient to take all the prescribed take home medications religiously.
: To facilitate faster recovery, prevent further complications, and alleviate pain.

Diet

Encourage patient to reduce eating fatty and salty foods and foods high in uric acid.
: Low salt and low fat diet is needed for faster recovery.

Instruct patient to increase Oral Fluid Intake.


Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

: To prevent dehydration.

BIBLIOGRAPHY

1. Marilyn E. Doenges, Mary Frances Moorhouse & Alice C. Geissler-Muris Nurses


Pocket Guide Diagnosis, Interventions and Rationales; 9th Edition; Pp. 240-244; pp.
256-260; pp. 232-236; pp.57-60; pp. 306-310

2. Gulanick & Myers Nursing Care Plans Nursing Diagnosis and Interventions; 6 th
Edition

3. Barbara E. Goulds Pathophysiology for the Health Professions; 3rd Edition; Pages
279-289

4. Josie Quiambao-Udans Health Assessment and Physical Examination Concepts


and Clinical Application; 1st Edition; Chapter 9; Page 251

5. Lippincott, Williams & Wilkins Nursing 2006 DRUG Handbook; 26th Edition
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis

6. Suzanne C. Smeltzer, Brenda G. Bare, Janice L. Hinkle & Kerry H. Cheevers


Brunner & Suddarths Textbook of Medical-Surgical Nursing; 11th
Edition;Volume 1

7. Judith Hopfer Deglin & April Hazard Vallerands Daviss Drug Guide for Nurses,
10th Edition

Websites:

1. www.yahoo.com
2. www.google.com
3. www.nursingcrib.com