I.

INTRODUCTION

Chronic kidney disease (CKD), also known as Chronic Renal Failure, is a progressive loss
of renal function over a period of months or years. The symptoms of a worsening kidney
function are unspecific, and might include feeling generally unwell and experiencing a reduced
appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to
be at risk of kidney problems, such as those with high blood pressure or diabetes and those with
a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when
it cardiovascular disease, anemia or pericarditis.
The kidneys fail in an organized fashion. Progression toward ESRD usually starts with a
gradual decrease in renal function of 30% to 50%.
Here are the 3 stages of CKD.

Stage 1: Diminished Renal Reserve

Renal function is reduced, but no accumulation of metabolic wastes occurs.
The healthier kidney compensates for the diseased kidney.
Ability to concentrate urine is decreased, resulting in nocturia and polyuria.
A 24 hour urine collection for creatinine clearance is necessary to detect that the renal reserve
is less than normal.

Stage 2: Renal Insufficiency

Metabolic wastes begin to accumulate in the blood because the unaffected nephrons can no
longer compensate.
Responsiveness to diuretics is deceased, resulting in oliguria and edema.
The degree of insufficiency is determined by the decreasing GFR and is classified as mild,
moderate and severe.
Treatment is medical.
Stage 3: End Stage Renal Disease
Excessive amounts of metabolic wastes such as urea and creatinine accumulate in the blood.

 The kidneys are unable to maintain homeostasis.

Treatment is by dialysis or other renal replacement therapy.
According to research the prognosis of patients with CKD is guarded as epidemiological
data has shown that all causes mortality increases as kidney function decreases. The Centers for
Disease Control and Prevention found that CKD affected an estimated 16.8% of adults aged 20
years and older during 2005 to 2011.
Age:
Age of 65 years old.
Gender:
Chronic Kidney Disease is more common in men than in women.
Genetics:
A family history of renal disease.

Race:
Chronic Kidney Disease is a major concern in Native American, African American and
Hispanic mostly due to increased prevalence of hypertension.
37% of ESRD cases in African Americans can be attributed to high blood pressure
Common Diseases:

 Heart Failure, Hypertension, Diabetes Mellitus and Glomerulonephritis.

PURPOSE AND OBJECTIVES

1. General Objectives
Aims to broaden the knowledge, skills and attitude of the student nurses and the members of

the health team about the disease.

To be able to respond, intervene, and render accurate nursing care to clients with Chronic
Kidney Disease

2. Specific Objectives
Understand the pathophysiology of Chronic Kidney Disease and determine the major disease

manifestations, risk factors and etiology

Formulate an effective nursing care plan and implement nursing interventions appropriately
based on the prioritized health needs of the client maintaining sound communication with the

patient and members of the health team.

Provide better nursing care and health teachings to their client through the utilization of the
nursing process.
SIGNIFICANCE AND JUSTIFICATION
The group chose this case because more clinical skills will be developed by experiencing

the clinical management of the disease condition and it will enhance ones knowledge in
implementing proper nursing intervention for the patient towards recovery. And it is the first time
the group has encountered this type of case.

SCOPE AND LIMITATIONS

The scope of the Chronic Kidney Disease encompasses the anatomy, physiology and

pathophysiology. The actual interaction with the client was done last July 24, 25, 26 and 30,
2014 on our hospital duty 6:00 am to 12:00 noon at Ospital ng Maynila Medical Center,
Medicine Ward. The group interviewed client G.L with her niece. The data was collected by

reading the chart, interviewing the client as well as with the help of the staff nurses assigned to
the client.

BACKGROUND OF THE STUDY

The site of the study was done at Ospital ng Maynila Medical Center, Medicine Ward. The

different diagnostic procedures and operation were done in the same institution.
The group chose this case study to know the disease, its clinical manifestations, risk
factors, pathophysiology and diagnostic procedure for the disease, to identify different medical
and nursing care management for patient with Chronic Kidney Disease.

II.

PRESENTATION OF THE CLIENT

A case of G.L. 49 years old from medicine ward female. A Filipina came from the ethnicity

of Bisaya. A Roman Catholic, High School Graduate, Housewife, from District II Tondo, Manila.
Patient was admitted for the second time at Ospital ng Maynila Medical Center last July
23, 2014 at exactly 8am. She was conscious and coherent and ambulatory accompanied by her
husband. 8 hours prior to admission the patient had an onset of difficulty of breathing. Patient
G.L was admitted with a chief complaint of difficulty of breathing.
The patient is known Diabetic for 2 years. She had no accident or injuries in the past and
no food or drug allergies. Last February 2013, she was diagnosed with PTB at Ospital ng

Maynila Medical Center. Her maintenance medications are Metformin 5mg OD per Orem and
Amlodipine 5mg OD per Orem.
Patient has a family history of Hypertension on paternal side and no known history on
maternal side. Her father died due to hypertension and her mother died due to labor on her. Her
youngest brother had Hypertension and her younger sister died on dengue.

COURSE IN THE WARD

Date

Doctors Order

Interventions

 Please admit to Philhealth Consent signed and secure

July 23, 2014
3:45 PM
Wednesday

ward
Secure consent for admission
and management
TPR every hour and record
Low salt low fat diet
Repeat the following:

Oriented client and family to

ward policies

Initial V/S taken

Explained diet to the client and
family
Maintained diet as ordered

> CBC, ABG, FBS, BUN, For referral to Nephrology

Creatinine, Lipid Profile, Na, K,

service

CXR, and 12 L ECG.

Kept safe and comfortable

Med.

Seen at times

1. Metformin 500mg/tab BID

2.Furosemide 40mg TIV Q8
3.Amlodipine 5mg/tab OD
4. NaHCO3 650mg/tab TID
5. Fe+FA OD
Refer for Anesthesia/ Surgery
for IJ catheterization
Refer to Nephro
Refer accordingly

 NPO from 9AM after a light

meal

July 24, 2014

Thursday
1:50PM

For IJ insertion scheduled at

3PM on July 25, 2014

( IJ insertion scheduled at 3PM Monitor vital signs

on July 25, 2014)
Anaesthesia Plan: local
infiltration with possible
sedation.

Consent signed, material on

bedside care of relative
Seen by the doctor with orders
made and carry out

Monitor vital signs every 4

hours and record
Make some of availability of
all necessary materials for IJ
insertion.
For PT, APTT with activity

Once with access for HD x 3

2:30PM

For HD once access

as

hours

ordered

UF= 1000cc

BFR= 150cc/min Plasil IV given as PRN as

Dialysate FR= 400cc/min.

ordered

Minimum heparinization.
Plasil 1 amp IV every 6 hours
PRN

6:40 PM

For blood typing

Please prepare and transfuse 1

For blood transfusion 1 unit

pack RBC as ordered

pack RBC properly typed and For blood typing as ordered

cross matched to run for 4
hours

Omeprazole

40mg IV now

was given

Increased FeSO4+FA 50g Supportive care rendered

1tab BID

Seen at times

 Omeprazole 40mg IV now

 Still for BT of 1U pack RBC Monitor vital signs

Of BT 1 U pack RBC

July 25, 2014

Rescheduled IJ insertion on

Friday

Monday July 28,2014

6:30pm

Supportive care rendered

Seen at times

July 26, 2014

For hepatitis C screening

Monitor vital signs

For hepatitis C screening

Saturday
11:30am

3:30pm

Start omeprazole 40mg TIV Omeprazole 40mg TIV

now then OD

given

Continue present management Supportive care rendered

July 27, 2014

Sunday
4:00pm

Refer accordingly

Seen at times

Still for IJ insertion

Monitor vital signs

Still for IJ insertion
Supportive care rendered
Seen at times

was

Anesthesia Notes
July 28, 2014
Monday
5:16pm

Referred

for

haemodialysis Monitor vital signs

catheter insertion
Aseptic

On HD on Wednesday July

technique,

infiltration

done,

local

30, 2014

attempted Supportive care rendered

right IJ and left IJ vein Seen at times

cannulation

-> unable to

thread guide wire on both sites

Right femoral vein cannulated,
Seldinger technique done, able
to aspirate blood from both
parts, secured to skin
Both parts locked if 1.33c of
1000 unit/ml of heparin
Patient

tolerated

procedure

well with stable vital signs

For chest X-ray

5:35pm

Chest

X-ray

reviewed

no

evidenced of pneumothorax on
both sides

10:30pm

For blood typing

Still for blood typing 2 units
pack RBC properly type and
properly cross matched

July 29, 2014

Still for blood transfusion

Discontinue IV
Omeprazole 40mg/tab OD

Monitor vital signs

For BT 2 units pack RBC
Supportive care rendered

Tuesday

Seen at times

9:30am

July 30, 2014

Wednesday
3:00 pm

Continue
management.

present
Monitor vital signs

Acetylcysteine 600mg/tab On low salt low fat diet

1 tab BID.

Supportive care rendered

Seen at times

LABORATORIES AND DIAGNOSTICS TEST

Lab Exam
BUN

Normal values
2.9 7.5 mmol/L

Actual findings
34.1 mmol/L

Analysis & Interpretation

Elevated levels: Renal
disease, reduced renal
blood flow (caused by
dehydration), urinary tract
obstruction, and increased
protein catabolism (such as
burns)

Creatinine

0.5-12 mg/dl

15 mg/dl

Elevated levels generally

indicate renal disease that
has seriously damaged
50% or more of the
nephrons.

FBS

4.11 5.9 mmol/L

5.2 mmol/L

Normal result

Potassium

3.5 5.0 mmol/L

5.0 mmol/L

Normal result

Triglyceride

0.40 2.25mmo/L

2.42mmo/L

A mild to moderate
increase in serum
triglyceride levels indicates
biliary obstruction,
diabetes mellitus, nephrotic
syndrome or over
consumption of alcohol.

Sodium

134 -145 mmol/L

138mmol/L

Normal result

Chloride

100-108 mmol/L

112 mmol/L

An increased in chloride
levels may be evident in

severe dehydration and

complete renal shutdown.

TOTAL

3.80 5.10 mmol/L

4.68 mmol/L

Normal result

CHOLESTEROL
HDL

0.87 1.94 mmol/L

1.08 mmol/L

Normal result

LDL

1.32 2.52 mmol/L

2.5 mmol/L

Normal result

WBC
Neutrophils

4.6 -10.0 10e9/L

0.60 0.70 10e9/L

6.6 10e9/L
.57 10e9/L

Normal result
A small number of slightly
immature neutrophils,
known as band cells, are

Lymphocytes
Monocytes
HGB

0.20 0.40 10e9/L

0-0.07 10e9/L
120 -180 10e9/L

.37 10e9/L
.04 10e9/L
82.10e9/L

HCT
Platelet

0.370 -0.540gm/L
150 450 10e9/L

.230gm/L
238.10e9/L

present in peripheral blood.

Normal result
Normal result
Low hemoglobin level may
indicate anemia, recent
hemorrhage, or fluid
retention causing
hemodilution.
Normal result
Normal result

Gordons Functional Health Pattern

PATTERNS OF
HEALTH

PRIOR TO
HOSPITALIZATION

DURING
HOSPITALIZATION

Analysis &
Interpretation

I. Health
perception and
health management
pattern

II. Nutrition and

metabolism
management

III. Elimination
pattern

>Patient G.L lifes before

confinement consults
medical doctor during
her sickness and doesnt
use any illegal drugs and
doesnt maintain good
health always eat
whatever she likes
especially salty and
sweet foods.

> During hospitalization

she maintains health by
avoiding salty, sweet
and fatty foods.

> Patient G.L lifes

before confinement she
eats whatever she likes.
She loves to eat salty,
sweet and fatty foods and
ate 3 times a day with
snack, had a good
appetite and drinks 8
glass of water.

>During hospitalization
her diet has been
controlled and limit
fluid intake 300 ml per
day as ordered.

> Before being

hospitalized, she voids 6
times a day and defecates
twice a day.

> During hospitalization

she does not void.

Health perception
changes as the
situation changes.
Knowledge about
health condition
expands.

Patient perceives
her health condition
as a hindrance
compared to the
previous illness she
experienced.

Having a nutritional
diet is necessary for
every individual to
live. Food is the
main source energy
which contributes to
meet physiologic
function.

Eat soft food. Must

receive adequate
nutrition while
recovering.

Elimination pattern
is necessary to
flushed out the
bacteria inside the
body moreover it is
a site of having
system that
functions well.

Unable to defecate
during
hospitalization.

IV. Activities and

exercise pattern

> According to her, she

always does the
household chores, and
had some 30 minutes
walk around their
community. Has self-care
hygiene and grooming,
sitting by her own,
getting up from bed and
changing clothes.

> During hospitalization

activities of daily living
become more limited.
Some activities require
assistance or
supervision.

V. Cognitive
perceptual pattern

>There are no changes in

her sensory ability; she is
verbally and physically
responsive.

>There are no changes

in her sensory ability;
she is verbally and
physically responsive.

VI. Sleep and rest

pattern

> Patient G.L lifes

before confinement she
sleeps 8 hours a day and
has no difficulty in
sleeping, does not wake
up in the middle of the
night.

> During hospitalization

she is always at her bed
and taking a nap
whenever possible.

The ability to move

provides mental
wellness and the
effectiveness of body
functioning depend
largely on their
mobility status
which could
influences the selfesteem and body
image.
Her condition affects
mobility and gait
wherein there are
already limitations in
performing
activities.
Humor is
increasingly valued
as both an
interpersonal skill
for nurse and a
healing strategy for
patients.
There are no changes
in her sensory
ability; she is
verbally responsive
to physical stimuli.
She has a competent
learning pattern.
Rest and sleep are
essential for health.
Rest implies
calmness, relaxation
without emotional
stress, and freedom
from anxiety. It

restores the energy

that has been used,
which allows the
person to resume
optimal functioning.

VII. Self-perception >She described herself as

and self-concept
cheerful, talkative and
pattern
not easily gets angry.

> Upon hospitalization

shes still cheerful and
gets worried about
simple things.

Upon
hospitalization the
number of her sleep
was lessen due to the
environmental
factors arising in the
hospital.

Self-concept is how
a person feels about
himself and
perceives the
physical health and
handle situations.
Such attitude can
affect health
practices, responses
to stress and illness
and the time when
treatment is sought.
Patient shows selfconfident.

VIII. Role and

>She has 1 daughter and
relationship pattern 2 siblings. Family
worries on her
hospitalization.

>She has 1 daughter and

2 siblings. Family
worries on her
hospitalization.

Relationship with
other family
members boosts her
self-esteem and selfconfidence allowing
her to cope with her
problem. Moreover,
a person having
health problems

needs self-esteem
and self-confidence
in order for her to
handle the situation
of the problem.

IX. Sexuality and

reproductive
pattern

>Menarche started at 13
years old. Has gravida 1,
para 1, preterm 0,
abortion 0, children
living 1.

Sexuality is a crucial
part of person`s
identity. Sex
determines who we
are to our emotional
well-being and to the
quality of our lives.
No sexual
intercourse had been
noted because she
was a widowed.

X. Coping stress
and tolerance
pattern

>She was able to cope

with her stress by taking
care of her grandchild
and she also manages her
stress by doing
household chores.

>During hospitalization
she was playing cards,
and listening to radio
and chatting to her
niece.

Coping strategies
vary from
individuals and are
often related to
individuals
perception of a
stressful events
strategy use by the
client was emotion
focus and a very
typical coping
strategies used by the
patient.

XI. Values and

belief pattern

>She has a strong faith in

God and prays often.

>During hospitalization
her faith in God
becomes stronger. She
always prays for her fast
recovery.

Values are learn

through observation
and experience as a
result they are
heavily influence by
a person, sociocultural environment

that is by societal
tradition, ethnic, and
religious group.

III.

ANALYSIS AND INTERPRETATION

In our study the client was diagnosed with chronic kidney disease, secondary to diabetes
mellitus nephropathy. Nephropathy is pathologic change in the kidney that reduces kidney
function and leads to renal failure. Chronic high blood glucose levels causes hypertension in
kidney blood vessels and excess kidney perfusion. The increased pressure damages the kidney in
many ways. The blood vessels become leakier, especially in the glomerulus. This leakiness
allows the filtration of larger particles (including albumin & other proteins) which then form
deposits in the kidney tissue & blood vessels. Deposits narrow the vessels, decreasing kidney
oxygenation & leading to kidney cell hypoxia & cell death. These processes worsen over time.
Blood vessels in the glomerulus become scarred & unable to filter urine from the blood, leading
to renal failure.

Diagnosis

Altered Breathing Pattern

Upon admission patient reported onset of difficulty of breathing. As per emergency room
record, respiratory rate is 26 breaths per minute. Patient had flaring nostrils and could not
tolerate flat lying position. The condition is probably due to lung congestion which resulted from
altered glomerular filtration that cause sodium retention that further holds fluid and congest the
lungs so the lungs cannot expand as usual. Patient experienced feeling of heaviness.

Risk for infection and Acute pain

Patient is schedule for IJ insertion. At 4:30pm, right jugular vein inserted failed. At 4:45pm

left jugular vein insertion attempt failed. And by 5:00pm right femoral vein insertion ended. Vital
signs taken as follows: blood pressure: 160/90mmHg; pulse rate 103 beats per minute;
respiratory rate 25 breaths per minute. Patient is then transferred into dialysis. Presence breakage
of skin provides possible entrance for microorganism making the patient risk for infection. Acute
pain is caused by multiple attempts for IJ insertion.

Non-compliance
Patient does not follow dietary advice of avoiding salty and fatty foods. She also doesnt

exercise regularly. There are times when patient forget to take her maintenance medication.

Excess fluid volume

Patient was ordered Furosemide 40mg TIV q8 for edema. Patient had increase blood

pressure 160/100mmHg and dyspnea. Complete blood count reveals decrease hemoglobin 86

e9/L, and decrease hematocrit 0.230gm/L. Blood chemistry reveals elevated BUN 34.1mmol/L
and elevated serum creatinine level 15.1mg/gl. The condition is probably due to increased fluid
retention which resulted from the malfunction of renin-angiotensin-aldosterone-system. The
damaged kidney does not recognize the increase in blood pressure and fluid and continue to
produce renin which stimulates the production of aldosterone which stimulates kidney tubules to
reabsorb sodium and water

IV.

SUMMARY OF THE FINDINGS, CONCLUSIONS AND RECOMMENDATIONS

Objective 1: Understand the pathophysiology of Chronic Kidney Disease and determine the
major disease manifestations, risk factors and etiology.

Pathophysiology:
Chronic Kidney Disease starts with a gradual decrease in renal function of 30-50%. At
first there is a diminished renal reserve. In this stage reduced renal function occurs without
accumulation of metabolic waste in the blood because of the unaffected nephrons overwork to
compensate for the diseased nephrons. Renal damage increases systemic blood pressure, which
also increases glomerular pressure and the pressure in the remaining unaffected nephrons.
Eventually, the unaffected nephrons may be damaged by this long term increased pressure,
causing the progressive renal damage of CRF. In the next stage renal insufficiency, metabolic
wastes begin to collect in the blood because of not enough healthy nephrons remain to

compensate completely for the non-functioning nephron. Level of BUN, serum creatinine, uric
acid, and phosphorus are elevated in proportion to the amount of nephrons lost. Over time, most
clients progress to ESRD. Excessive amount of urea and creatinine build up in the blood, and the
kidneys cannot maintain homeostasis. Severe fluid, electrolyte, and acid-base balances occurs.
Without renal replacement therapy, fatal complications are likely.
Manifestations:
Chronic kidney disease initially without specific symptoms and is generally only detected
as increase in serum creatinine or protein in the urine. The client may also experience nausea,
vomiting, loss of appetite, fatigue and weakness, sleep problems, changes in urine output,
swelling of feet and ankles, chest pain, shortness of breath and high blood pressure. Also patient
with chronic kidney disease suffer from accelerated atherosclerosis and are more likely to
develop cardiovascular disease than the general population.
Etiology:
Three main causes of CKD are Diabetes Mellitus, Hypertension and Glomerulonephritis.
Risk factors:
Race: Native American, African American, Hispanic. Age: 65 years old. Genetics:
Family history of renal disease. Certain diseases like Heart Failure, Hypertension, DM and
Glumerulonephritis.
Objective 2: Analyze, assist and interpret the different diagnostic and laboratory procedures, its
purpose and relationship to clients disease condition.

BUN

Elevated levels: renal disease, reduced renal blood flow (caused by dehydration), urinary tract
obstruction, and increased protein catabolism (such as burns)

TRIGLYCERIDE.

Markedly increased levels without an identifiable cause reflect congenital hyperlipoproteinemia

and necessitate lipoprotein phenotyping to confirm the diagnosis.

CHLORIDE.

Decreased levels may result from excessive diaphoresis, heart failure, hypochloremic metabolic
alkalosis, or prolonged vomiting gastric suctioning.

Objective 3: Provide better nursing care and health teachings to their client through the
utilization of the nursing process.
Problem: Altered breathing pattern related to decreased lung expansion as evidenced by
difficulty of breathing.
Interventions:
Position with proper body alignment for optimal breathing pattern.
Provide relaxation training as appropriate
Administer oxygen at lowest concentration.
Encourage adequate rest period between activities.

 Problem: Altered comfort related to pain as evidenced by previous IJ insertion

Interventions:
Provide rest period to facilitate comfort, sleep & relaxation.
Apply warm compress
Encourage diversional activities
Provide calm & quiet environment
Instruct use of relaxation exercise such as focused breathing.
Problem: Excess fluid volume related to end stage renal failure
Interventions :
Measure I&O every 2-4 hours, and notify physician if imbalances are significant
Maintain patients dietary restrictions, including fluid restrictions. Post signs and remove

water pitcher from room.

Monitor vital signs every 2 hours and PRN. Notify physician for significant changes.
Observe patient and assess for degree of edema to extremities and periphery
Monitor lab work for BUN, Creatinine, and electrolyte levels

Problem: Risk for infection related to insufficient knowledge to avoid exposure to pathogen
Interventions :
Observe for localized sign of infection at insertion sites of invasive line, sutures, and

surgical wounds.
Assess and document skin conditions around insertions of pins, wires and tongs noting

inflammation and drainage.

Noting signs and symptoms of sepsis: fever, chills, diaphoresis, altered level of

consciousness, positive blood culture.

Instruct client in techniques to protect the integrity of skin, care for lesions and
prevention of spread of infection

Problem: Non-compliance to difficulty changing behaviour.

Interventions:
Develop therapeutic nurse-client relationship.
Encourage client to maintain self-care, providing for assistance when necessary.
Provide for continuity of care in and out of the hospital/ care setting, including longrange plans.

Provide information and help client to know where and how to find it on her own.
Give information in manageable amounts using verbal, written, and auto visual modes at
level of clients ability.

Conclusion
Since the patient suffered from Chronic kidney disease, the related factors that promoted
meeting of needs is to prevent or slow further damage to the kidneys, and monitor conditions
such as diabetes or high blood pressure that usually causes kidney disease, so it is important to
identify and manage the condition that is causing the kidney disease. It is also important to
prevent diseases and avoid situations that can cause kidney damage or make it worst.

Competencies of nurses that promoted the meeting of needs include ensuring safety and
privacy, alleviating discomfort, monitoring vital signs on time and instructing the client to follow
the diet that is recommended by the physician. Strict blood pressure control is a high priority in
the care of the patient with chronic kidney disease. For the reasons mentioned above, ACE
inhibitors are commonly used as the initial medications to achieve blood pressure control;
however, often a multidrug regimen is needed. Commonly, diuretics are needed for patients with
chronic kidney disease because of the hypertensive effect of volume overload. Regardless of the
cause of CKD, tight glycemic control should be achieved for all diabetic patients. Administering
insulin is recommended to control further complications and increase in blood glucose level.

Altered breathing pattern related to decreased lung expansion

- This problem is solved as evidenced by respiratory rate of 19 breaths per
minute.

Excess fluid volume related to end stage renal failure

- This problem is still unresolved as evidenced by bipedal edema.

Altered comfort related to pain

- This problem is partially resolved as evidenced by reduced pain as verbalized
by the patient. PS: 3/10

Risk for Infection related to insufficient knowledge to avoid exposure to

pathogens
- This problem is resolved. Patient verbalized understanding of ways to prevent
infection.

Non-Compliance related to difficulty changing lifestyle particularly diet and

medication regimen.
- This problem is resolved. Patient verbalized understanding of disease
condition and importance of following treatment regimen.

Recommendation
After conducting the case study and finding the clients response to interventions, we recommend
the following:
Student nurses should properly assess the clients level of understanding of her disease
condition, and provide appropriate nursing interventions and other health care follow ups.
Student nurses should provide appropriate management base on the physical assessment,
Gordons functional pattern and laboratory and diagnostics findings.