chronic kidney disease secondary to dm nephropathy

8/20/2019 Chronic Kidney Disease Secondary to DM Nephropathy

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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. he symptoms of a worsening kidney

function are unspecific, and might include feeling generally unwell and e!periencing a reduced

appetite. "ften, chronic kidney disease is diagnosed as a result of screening of people known to

#e at risk of kidney pro#lems, such as those with high #lood pressure or dia#etes and those with

a #lood relative with chronic kidney disease. Chronic kidney disease may also #e identified when

it cardiovascular disease, anemia or pericarditis.

he kidneys fail in an organi$ed fashion. %rogression toward &'RD usually starts with a

gradual decrease in renal function of * to +*.

ere are the stages of CKD.

Stage 1: Diminished Renal Reserve

Renal function is reduced, #ut no accumulation of meta#olic wastes occurs.

he healthier kidney compensates for the diseased kidney.

-#ility to concentrate urine is decreased, resulting in nocturia and polyuria.

- / hour urine collection for creatinine clearance is necessary to detect that the renal reserve

is less than normal.

Stage 2: Renal Insufficiency

0eta#olic wastes #egin to accumulate in the #lood #ecause the unaffected nephrons can no

longer compensate.

Responsiveness to diuretics is deceased, resulting in oliguria and edema.

he degree of insufficiency is determined #y the decreasing 1FR and is classified as mild,

moderate and severe.

reatment is medical.

Stage : !nd Stage Renal Disease

&!cessive amounts of meta#olic wastes such as urea and creatinine accumulate in the #lood.


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he kidneys are una#le to maintain homeostasis.

reatment is #y dialysis or other renal replacement therapy.

-ccording to research the prognosis of patients with CKD is guarded as epidemiological

data has shown that all causes mortality increases as kidney function decreases. he Centers for

Disease Control and %revention found that CKD affected an estimated 23.4* of adults aged

years and older during + to 22.

"ge:

-ge of 5 3+ years old.

#ender:

Chronic Kidney Disease is more common in men than in women.

#enetics:

- family history of renal disease.

Race:

Chronic Kidney Disease is a ma6or concern in 7ative -merican, -frican -merican and

ispanic mostly due to increased prevalence of hypertension.

8* of &'RD cases in -frican -mericans can #e attri#uted to high #lood pressure

C$mm$n Diseases:


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eart Failure, ypertension, Dia#etes 0ellitus and 1lomerulonephritis.

%UR%OS! "ND O&'!CTI(!S

1. #eneral O)*ectives

-ims to #roaden the knowledge, skills and attitude of the student nurses and the mem#ers of

the health team a#out the disease.

o #e a#le to respond, intervene, and render accurate nursing care to clients with Chronic

Kidney Disease

2. S+ecific O)*ectives

9nderstand the pathophysiology of Chronic Kidney Disease and determine the ma6or disease

manifestations, risk factors and etiology

Formulate an effective nursing care plan and implement nursing interventions appropriately

#ased on the prioriti$ed health needs of the client maintaining sound communication with the

patient and mem#ers of the health team.

%rovide #etter nursing care and health teachings to their client through the utili$ation of the

nursing process.

SI#NI,IC"NC! "ND 'USTI,IC"TION

he group chose this case #ecause more clinical skills will #e developed #y e!periencing

the clinical management of the disease condition and it will enhance one:s knowledge in

implementing proper nursing intervention for the patient towards recovery. -nd it is the first time

the group has encountered this type of case.

SCO%! "ND -IIT"TIONS

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

pathophysiology. he actual interaction with the client was done last ;uly /, +, 3 and ,

2/ on our hospital duty 3


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

the client.

&"C/#ROUND O, T0! STUD

he site of the study was done at "spital ng 0aynila 0edical Center, 0edicine =ard. he

different diagnostic procedures and operation were done in the same institution.

he 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. %R!S!NT"TION O, T0! C-I!NT

- case of 1.>. /? years old from medicine ward female. - Filipina came from the ethnicity

of @isaya. - Roman Catholic, igh 'chool 1raduate, ousewife, from District AA ondo, 0anila.

%atient was admitted for the second time at "spital ng 0aynila 0edical Center last ;uly

, 2/ at e!actly 4am. 'he was conscious and coherent and am#ulatory accompanied #y her

hus#and. 4 hours prior to admission the patient had an onset of difficulty of #reathing. %atient

1.> was admitted with a chief complaint of difficulty of #reathing.

he patient is known Dia#etic for years. 'he had no accident or in6uries in the past and

no food or drug allergies. >ast Fe#ruary 2, she was diagnosed with %@ at "spital ng


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0aynila 0edical Center. er maintenance medications are 0etformin +mg "D per "rem and

-mlodipine +mg "D per "rem.

%atient has a family history of ypertension on paternal side and no known history on

maternal side. er father died due to hypertension and her mother died due to la#or on her. er

youngest #rother had ypertension and her younger sister died on dengue.

COURS! IN T0! "RD

Date D$ct$r3s Order Interventi$ns


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;uly , 2/

ipid %rofile, 7a, K,

CR, and 2 > &C1.

0ed.

2. 0etformin +mgta# @AD

.Furosemide /mg AE 4

.-mlodipine +mgta# "D

/. 7aC" 3+mgta# AD

+. FeGF- "D

Refer for -nesthesia 'urgery

for A; catheteri$ation

Refer to 7ephro

Refer accordingly

Consent signed and secure

"riented client and family to

ward policies

Anitial E' taken

&!plained diet to the client and

family

0aintained diet as ordered

For referral to 7ephrology

service

Kept safe and comforta#le

'een at times


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;uly /, 2/

hursday

2


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"mepra$ole /mg AE now


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;uly 4, 2/

0onday

+


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;uly ?, 2/

uesday

?


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-"&OR"TORI!S "ND DI"#NOSTICS T!ST

-a) !4am N$rmal values "ctual findings "nalysis 5 Inter+retati$n

@97 .? L 8.+ mmol> /.2 mmol> &levated levels< Renal

disease, reduced renal

#lood flow (caused #y

dehydration), urinary tract

o#struction, and increased

protein cata#olism (such as

#urns)

Creatinine .+2 mgdl 2+ mgdl &levated levels generally

indicate renal disease that

has seriously damaged

+* or more of the

nephrons.

F@' /.22 L +.? mmol> +. mmol> 7ormal result

%otassium .+ L +. mmol> +. mmol> 7ormal result

riglyceride ./ L .+mmo> ./mmo> - mild to moderate

increase in serum

triglyceride levels indicates

#iliary o#struction,

dia#etes mellitus, nephrotic

syndrome or over

consumption of alcohol.

'odium 2/ 2/+ mmol> 24mmol> 7ormal result

Chloride 224 mmol> 22 mmol> -n increased in chloride

levels may #e evident in


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severe dehydration and

complete renal shutdown.

"->

C">&'&R">

.4 L +.2 mmol> /.34 mmol> 7ormal result

D> .48 L 2.?/ mmol> 2.4 mmol> 7ormal result

>D> 2. L .+ mmol> .+ mmol> 7ormal result

=@C /.3 2. 2e?> 3.3 2e?> 7ormal result

7eutrophils .3 L .8 2e?> .+8 2e?> - small num#er of slightly

immature neutrophils,

known as #and cells, are

present in peripheral #lood.

>ymphocytes . L ./ 2e?> .8 2e?> 7ormal result

0onocytes .8 2e?> ./ 2e?> 7ormal result

1@ 2 24 2e?> 4.2e?> >ow hemoglo#in level may

indicate anemia, recent

hemorrhage, or fluid

retention causing

hemodilution.

C .8 .+/gm> .gm> 7ormal result

%latelet 2+ L /+ 2e?> 4.2e?> 7ormal result

#$rd$n3s ,uncti$nal 0ealth %attern

%"TT!RNS O,

0!"-T0

%RIOR TO

0OS%IT"-I6"TION

DURIN#

0OS%IT"-I6"TION

"nalysis 5

Inter+retati$n


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I. 0ealth

+erce+ti$n and

health management

+attern

B%atient 1.> life:s #efore

confinement consults

medical doctor during

her sickness and doesn:t

use any illegal drugs and

doesn:t maintain good

health always eat

whatever she likes

especially salty and

sweet foods.

B During hospitali$ation

she maintains health #y

avoiding salty, sweet

and fatty foods.

• ealth perception

changes as the

situation changes.

Knowledge a#out

health condition

e!pands.

• %atient perceives

her health condition

as a hindrance

compared to the

previous illness she

e!perienced.

II. Nutriti$n and

meta)$lism

management

B %atient 1.> life:s

#efore confinement she

eats whatever she likes.

'he loves to eat salty,

sweet and fatty foods and

ate times a day with

snack, had a good

appetite and drinks 4

glass of water.

BDuring hospitali$ation

her diet has #een

controlled and limit

fluid intake ml per

day as ordered.

• aving a nutritional

diet is necessary for

every individual to

live. Food is the

main source energy

which contri#utes to

meet physiologic

function.

• &at soft food. 0ust

receive adeJuatenutrition while

recovering.

III. !liminati$n

+attern

B @efore #eing

hospitali$ed, she voids 3

times a day and defecates

twice a day.


she does not void.

• &limination pattern

is necessary to

flushed out the

#acteria inside the

#ody moreover it is

a site of having

system that

functions well.

• 9na#le to defecate

during

hospitali$ation.


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I(. "ctivities and

e4ercise +attern

B -ccording to her, she

always does the

household chores, and

had some minutes:

walk around their

community. as selfcare

hygiene and grooming,

sitting #y her own,

getting up from #ed and

changing clothes.


activities of daily living

#ecome more limited.

'ome activities reJuire

assistance or

supervision.

• he a#ility to move

provides mental

wellness and the

effectiveness of #ody

functioning depend

largely on their

mo#ility status

which could

influences the self

esteem and #ody

image.

• er condition affects

mo#ility and gait

wherein there are

already limitations in performing

activities.

(. C$gnitive

+erce+tual +attern

Bhere are no changes in

her sensory a#ilityM she is

ver#ally and physically

responsive.

Bhere are no changes

in her sensory a#ilityM

she is ver#ally and

physically responsive.

• umor is

increasingly valued

as #oth an

interpersonal skill

for nurse and a

healing strategy for

patients.• here are no changes

in her sensory

a#ilityM she is

ver#ally responsive

to physical stimuli.

'he has a competent

learning pattern.

(I. Slee+ and rest

+attern

B %atient 1.> life:s

#efore confinement she

sleeps 4 hours a day and

has no difficulty in

sleeping, does not wake

up in the middle of the

night.


she is always at her #ed

and taking a nap

whenever possi#le.

• Rest and sleep are

essential for health.

Rest implies

calmness, rela!ation

without emotional

stress, and freedom

from an!iety. At


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restores the energy

that has #een used,

which allows the

person to resume

optimal functioning.

• 9pon

hospitali$ation the

num#er of her sleep

was lessen due to the

environmental

factors arising in the

hospital.

(II. Self7+erce+ti$n

and self7c$nce+t

+attern

B'he descri#ed herself as

cheerful, talkative and

not easily gets angry.

B 9pon hospitali$ation

she:s still cheerful and

gets worried a#out

simple things.

• 'elfconcept is how

a person feels a#out

himself and

perceives the

physical health and

handle situations.

'uch attitude can

affect health

practices, responses

to stress and illness

and the time when

treatment is sought.

• %atient shows self

confident.

(III. R$le and

relati$nshi+ +attern

B'he has 2 daughter and

si#lings. Family

worries on her

hospitali$ation.

B'he has 2 daughter and

si#lings. Family

worries on her

hospitali$ation.

• Relationship with

other family

mem#ers #oosts her

selfesteem and self

confidence allowing

her to cope with her

pro#lem. 0oreover,

a person having

health pro#lems


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needs selfesteem

and selfconfidence

in order for her to

handle the situation

of the pro#lem.

I8. Se4uality and

re+r$ductive

+attern

B0enarche started at 2years old. as gravida 2,

para 2, preterm ,

a#ortion , childrenliving 2.

• 'e!uality is a crucial

part of personNs

identity. 'e!

determines who we

are to our emotional

well#eing and to the

Juality of our lives.

•

7o se!ualintercourse had #een

noted #ecause she

was a widowed.

8. C$+ing stress

and t$lerance

+attern

B'he was a#le to cope

with her stress #y takingcare of her grandchild

and she also manages her

stress #y doing

household chores.

BDuring hospitali$ation

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 #y the

client was emotion

focus and a very

typical coping

strategies used #y the

patient.

8I. (alues and)elief +attern

B'he has a strong faith in

1od and prays often.

BDuring hospitali$ationher faith in 1od #ecomes stronger. 'he

always prays for her fast

recovery.

• Ealues are learn

through o#servation

and e!perience as a

result they are

heavily influence #y

a person, socio

cultural environment


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that is #y societal

tradition, ethnic, and

religious group.

III. "N"-SIS "ND INT!R%R!T"TION

An our study the client was diagnosed with chronic kidney disease, secondary to dia#etes

mellitus nephropathy. 7ephropathy is pathologic change in the kidney that reduces kidney

function and leads to renal failure. Chronic high #lood glucose levels causes hypertension in

kidney #lood vessels and e!cess kidney perfusion. he increased pressure damages the kidney in

many ways. he #lood vessels #ecome leakier, especially in the glomerulus. his leakiness

allows the filtration of larger particles (including al#umin O other proteins) which then form

deposits in the kidney tissue O #lood vessels. Deposits narrow the vessels, decreasing kidney

o!ygenation O leading to kidney cell hypo!ia O cell death. hese processes worsen over time.

@lood vessels in the glomerulus #ecome scarred O una#le to filter urine from the #lood, leading

to renal failure.

Diagn$sis

"ltered &reathing %attern


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9pon admission patient reported onset of difficulty of #reathing. -s per emergency room

record, respiratory rate is 3 #reaths per minute. %atient had flaring nostrils and could not

tolerate flat lying position. he condition is pro#a#ly 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 e!pand as usual. %atient e!perienced feeling of heaviness.

•Ris9 f$r infecti$n and "cute +ain

%atient is schedule for A; insertion. -t /


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compensate completely for the nonfunctioning nephron. >evel of @97, serum creatinine, uric

acid, and phosphorus are elevated in proportion to the amount of nephrons lost. "ver time, most

clients progress to &'RD. &!cessive amount of urea and creatinine #uild up in the #lood, and the

kidneys cannot maintain homeostasis. 'evere fluid, electrolyte, and acid#ase #alances occurs.

=ithout renal replacement therapy, fatal complications are likely.

anifestati$ns:

Chronic kidney disease initially without specific symptoms and is generally only detected

as increase in serum creatinine or protein in the urine. he client may also e!perience nausea,

vomiting, loss of appetite, fatigue and weakness, sleep pro#lems, changes in urine output,

swelling of feet and ankles, chest pain, shortness of #reath and high #lood pressure. -lso patient

with chronic kidney disease suffer from accelerated atherosclerosis and are more likely to

develop cardiovascular disease than the general population.

!ti$l$gy:

hree main causes of CKD are Dia#etes 0ellitus, ypertension and 1lomerulonephritis.

Ris9 fact$rs:

Race< 7ative -merican, -frican -merican, ispanic. -ge< 5 3+ years old. 1enetics<

Family history of renal disease. Certain diseases like eart Failure, ypertension, D0 and

1lumerulonephritis.

O)*ective 2: -naly$e, assist and interpret the different diagnostic and la#oratory procedures, its

purpose and relationship to client:s disease condition.

http://en.wikipedia.org/wiki/Atherosclerosishttp://en.wikipedia.org/wiki/Cardiovascular_diseasehttp://en.wikipedia.org/wiki/Cardiovascular_diseasehttp://en.wikipedia.org/wiki/Atherosclerosis


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• &UN

&levated levels< renal disease, reduced renal #lood flow (caused #y dehydration), urinary tract

o#struction, and increased protein cata#olism (such as #urns)

• TRI#-C!RID!.

P0arkedly increased levels without an identifia#le cause reflect congenital hyperlipoproteinemia

and necessitate lipoprotein phenotyping to confirm the diagnosis.

• C0-ORID!.

Decreased levels may result from e!cessive diaphoresis, heart failure, hypochloremic meta#olic

alkalosis, or prolonged vomiting gastric suctioning.

O)*ective : %rovide #etter nursing care and health teachings to their client through the

utili$ation of the nursing process.

%r$)lem: -ltered #reathing pattern related to decreased lung e!pansion as evidenced #y

difficulty of #reathing.

Anterventions<

• %osition with proper #ody alignment for optimal #reathing pattern.

• %rovide rela!ation training as appropriate

• -dminister o!ygen at lowest concentration.

• &ncourage adeJuate rest period #etween activities.


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%r$)lem< -ltered comfort related to pain as evidenced #y previous A; insertion

Anterventions<

• %rovide rest period to facilitate comfort, sleep O rela!ation.

• -pply warm compress

• &ncourage diversional activities• %rovide calm O Juiet environment

• Anstruct use of rela!ation e!ercise such as focused #reathing.

%r$)lem: &!cess fluid volume related to end stage renal failure

Anterventions <

• 0easure AO" every / hours, and notify physician if im#alances are significant

• 0aintain patient:s dietary restrictions, including fluid restrictions. %ost signs and remove

water pitcher from room.• 0onitor vital signs every hours and %R7. 7otify physician for significant changes.

• "#serve patient and assess for degree of edema to e!tremities and periphery

• 0onitor la# work for @97, Creatinine, and electrolyte levels

%r$)lem< Risk for infection related to insufficient knowledge to avoid e!posure to pathogen

Anterventions <

• "#serve for locali$ed sign of infection at insertion sites of invasive line, sutures, and

surgical wounds.

• -ssess and document skin conditions around insertions of pins, wires and tongs noting

inflammation and drainage.

• 7oting signs and symptoms of sepsis< fever, chills, diaphoresis, altered level of

consciousness, positive #lood culture.

• Anstruct client in techniJues to protect the integrity of skin, care for lesions and

prevention of spread of infection

%r$)lem: 7oncompliance to difficulty changing #ehaviour.

Anterventions<

• Develop therapeutic nurseclient relationship.

• &ncourage client to maintain selfcare, providing for assistance when necessary.

• %rovide for continuity of care in and out of the hospital care setting, including long

range plans.


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• %rovide information and help client to know where and how to find it on her own.

• 1ive information in managea#le amounts using ver#al, written, and auto visual modes at

level of client:s a#ility.

C$nclusi$n

'ince 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 dia#etes or high #lood pressure that usually causes kidney disease, so it is important to

identify and manage the condition that is causing the kidney disease. At 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 #y the physician. 'trict #lood pressure control is a high priority in

the care of the patient with chronic kidney disease. For the reasons mentioned a#ove, -C&

inhi#itors are commonly used as the initial medications to achieve #lood pressure controlM

however, often a multidrug regimen is needed. Commonly, diuretics are needed for patients with

chronic kidney disease #ecause of the hypertensive effect of volume overload. Regardless of the

cause of CKD, tight glycemic control should #e achieved for all dia#etic patients. -dministering

insulin is recommended to control further complications and increase in #lood glucose level.

• -ltered #reathing pattern related to decreased lung e!pansion

- his pro#lem is solved as evidenced #y respiratory rate of 2? #reaths per

minute.


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• &!cess fluid volume related to end stage renal failure

- his pro#lem is still unresolved as evidenced #y #ipedal edema.

• -ltered comfort related to pain

- his pro#lem is partially resolved as evidenced #y reduced pain as ver#ali$ed

#y the patient. %'< 2

• Risk for Anfection related to insufficient knowledge to avoid e!posure to

pathogens- his pro#lem is resolved. %atient ver#ali$ed understanding of ways to prevent

infection.

• 7onCompliance related to difficulty changing lifestyle particularly diet and

medication regimen.- his pro#lem is resolved. %atient ver#ali$ed understanding of disease

condition and importance of following treatment regimen.

Rec$mmendati$n

-fter conducting the case study and finding the client:s response to interventions, we recommend

the following<

'tudent nurses should properly assess the client:s level of understanding of her disease

condition, and provide appropriate nursing interventions and other health care follow ups. 'tudent nurses should provide appropriate management #ase on the physical assessment,

1ordon:s functional pattern and la#oratory and diagnostics findings.

chronic kidney disease secondary to dm nephropathy

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