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Southern Luzon State University
College of Allied Medicine
Lucban, Quezon
Pyomyositis
A CASE STUDY PRESENTED TO:
Mrs. Dulce
(clinical instructor)
In Partial Fulfillment of the Requirements in the Subject:
NCM 104: Related Learning Experience
Submitted by:
Rhealyca E. Mendoza
(Group 1)
October 12, 2009
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I. LEARNING OBJECTIVES
A. General Objectives
After establishing a nurse-patient interaction, providing care to the client and by a
thorough assessment and careful study about the patient’s condition, student will be able to
gain knowledge, develop skills and enhance attitude to determine appropriate care and
management in patients having Chronic Kidney Disease.
B. Specific Objectives
Given the opportunity to conduct study and render care to the patient with chronic kidney
disease, the student will be able to:
1. Define and Understand what Chronic Kidney Disease is.
2. Distinguishes its clinical manifestations, epidemiology and predisposing factors.
3. Present anatomy and physiology.
4. Outline the pathophysiology of the disease condition.
5. Establish a good and effective nurse-patient interaction.
6. Determine health status of the patient through:
a. General Data
b. Physical Assessment
c. Past and Present History of the Illness
d. Family Health History
e. Personal and Social History
7. Analyzing the laboratory examination done and correlate it to the present
condition of the patient. Determine the appropriate nursing care that should be
provided to the client:
a. Be familiar to the different medical procedures done to the patient.
b. Understands the different drugs that the client is taking and determine how it
will benefit the client as well as the possible adverse effects it may give.
c. Evaluate the effectiveness of NCP and medical treatment
8. Create a good and therapeutic nurse-patient relationship.
9. Teach the client’s relatives as well as other people on how to minimize the risk of
developing chronic kidney disease.
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II. INTRODUCTION
Chronic kidney disease is when one suffers from gradual and usually permanent loss of
kidney function over time. This happens gradually over time, usually months to years. Chronic
kidney disease is divided into five stages of increasing severity. Stage 5 chronic kidney failure is
also referred to as end-stage renal disease, wherein there is total or near-total loss of kidney
function and patients need dialysis or transplantation to stay alive. The term "renal" refers to the
kidney, so another name for kidney failure is "renal failure." Mild kidney disease is often called
renal insufficiency.
1,212,306 adult Filipinos have CKD (NNHeS 2003-2004 Renal Report), a figure that
is remarkably noticeable because of its increase and continuously rise as years passes by. The
common causes of the disease are diabetes and high blood pressure which are life-style related.
Most kidney diseases attack the nephrons, causing them to lose their filtering capacity. Damage
to the nephrons may happen quickly, often as the result of injury or poisoning. But most kidney
diseases destroy the nephrons slowly and silently. Only after years or even decades will the
damage become apparent. Most kidney diseases attack both kidneys simultaneously.
Chronic kidney disease is identified by a blood test for creatinine. Higher levels of
creatinine indicate a falling glomerular filtration rate and as a result a decreased capability of the
kidneys to excrete waste products. Creatinine levels may be normal in the early stages of CKD,and the condition is discovered if urinalysis shows that the kidney is allowing the loss of protein
or red blood cells into the urine. To fully investigate the underlying cause of kidney damage,
various forms of medical imaging, blood tests and often renal biopsy are employed to find out if
there is a reversible cause for the kidney malfunction.
OVERVIEW OF THE DISEASE
A. DEFINITION
Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss
of renal function over a period of months or years. The symptoms of 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 leads
to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis.
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B. SYMPTOMS
The kidneys are remarkable in their ability to compensate for problems in their function.
That is why chronic kidney disease may progress without symptoms for a long time until only
very minimal kidney function is left.
The kidneys perform so many functions for the body; kidney disease can affect the body
in a large number of different ways. Symptoms vary greatly. Several different body systems may
be affected. Most patients have no decrease in urine output even with very advanced chronic
kidney disease.
• Fatigue and weakness (from anemia or accumulation of waste products in the body)
• Loss of appetite, nausea and vomiting
• Need to urinate frequently, especially at night
• Swelling of the legs and puffiness around the eyes (fluid retention)
• Itching, easy bruising, and pale skin (from anemia)
• Headaches, numbness in the feet or hands (peripheral neuropathy), disturbed sleep,
altered mental status (encephalopathy from the accumulation of waste products or uremic
poisons), and restless legs syndrome
• High blood pressure, chest pain due to pericarditis (inflammation around the heart)
• Shortness of breath from fluid in lungs
• Bleeding (poor blood clotting)
• Bone pain and fractures
• Decreased sexual interest and erectile dysfunction
C. CAUSES
Although chronic kidney disease sometimes results from primary diseases of the kidneys
themselves, the major causes are diabetes and high blood pressure.
• Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy.
• High blood pressure (hypertension), if not controlled, can damage the kidneys over time.
• Glomerulonephritis is the inflammation and damage of the filtration system of the
kidneys and can cause kidney failure. Postinfectious conditions and lupus are among the
many causes of glomerulonephritis.
• Polycystic kidney disease is an example of a hereditary cause of chronic kidney disease
wherein both kidneys have multiple cysts.
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• Use of analgesics such as acetaminophen and ibuprofen regularly over long durations of
time can cause analgesic nephropathy. Certain other medications can also damage the
kidneys.
• Clogging and hardening of the arteries (atherosclerosis) leading to the kidneys causes a
condition called ischemic nephropathy.
• Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowings),
or cancers may also cause kidney disease.
• Other causes of chronic kidney disease include HIV infection, sickle cell disease, heroine
abuse, amyloidosis, kidney stones, chronic kidney infections, and certain cancers.
D. STAGES
All individuals with a Glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for 3
months are classified as having chronic kidney disease, irrespective of the presence or absence of
kidney damage. The rationale for including these individuals is that reduction in kidney function
to this level or lower represents loss of half or more of the adult level of normal kidney function,
which may be associated with a number of complications.
All individuals with kidney damage are classified as having chronic kidney disease,
irrespective of the level of GFR. The rationale for including individuals with GFR 60
mL/min/1.73 m2 is that GFR may be sustained at normal or increased levels despite substantial
kidney damage and that patients with kidney damage are at increased risk of the two major
outcomes of chronic kidney disease: loss of kidney function and development of cardiovascular
disease.
Stages of Chronic Kidney Disease
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Stage Description
GFR (mL per minute
per 1.73 m2) Metabolic consequences
- At increased risk Higher than 60 (with
risk factors for chronic
kidney disease)
-
1 Kidney damage (early) with
normal or elevated GFR
90 or higher -
2 Kidney damage with mildly
decreased GFR (early renal
insufficiency)
60 to 89* Parathyroid hormone level begins to
rise (GFR of 60 to 80).
3 Moderately decreased GFR
(moderate kidney failure)
30 to 59 Calcium absorption decreases (GFR
below 50).
Lipoprotein activity declines.
Malnutrition develops.There is onset of left ventricular
hypertrophy and/or anemia
(erythropoietin deficiency).
4 Severely decreased GFR
(pre-end-stage kidney
disease)
15 to 29 Triglyceride concentration begins to
rise.
Hyperphosphatemia or metabolic
acidosis develops.
There is a tendency toward
hyperkalemia.
5 Kidney failure < 15 (or dialysis) Azotemia develops.
E. RISK FACTORS
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• Diabetes mellitus type 1 or 2
It is a chronic disease associated with abnormally high levels of the sugar glucose
in the blood. Diabetes is due inadequate production of insulin or inadequate sensitivity of
cells to the action of insulin.
• High blood pressure
It is a repeatedly elevated blood pressure exceeding 140 over 90 mmHg -- a
systolic pressure above 140 with a diastolic pressure above 90.
• High cholesterol
It is the fatty deposits in your blood vessels. Eventually, these deposits make it
difficult for enough blood to flow through your arteries.
• Heart disease
It is any disorder that affects the heart. Heart disease is synonymous with cardiac
disease but not with cardiovascular disease which is any disease of the heart or blood
vessels
• Liver disease
Liver disease refers to any disorder of the liver. The liver is a large organ in the
upper right abdomen that aids in digestion and removes waste products from the blood.
• Kidney disease
Kidney disease is any disease or disorder that affects the function of the kidneys
which affects the rate of filtration of the nephrons.
• Amyloidosis
It is any disorder that results from the abnormal deposition of a particular protein,
called amyloid, in various tissues of the body. Amyloid protein can be deposited in a
localized area, and not be harmful, or in can cause serious changes in virtually any organ
of the body.
• Sickle cell disease
It is agenetic blood disease due to the presence of an abnormal form of
hemoglobin, namely hemoglobin S. Hemoglobin is the molecule in red blood cells that
transports oxygen from the lungs to the farthest reaches of the body.
• Systemic Lupus erythematosus
It is a chronic inflammatory condition caused by an autoimmune disease. An
autoimmune disease occurs when the body's tissues are attacked by its own immune
system. Patients with lupus have unusual antibodies in their blood that are targeted
against their own body tissues.
• Vascular diseases such as arteritis, vasculitis, or fibromuscular dysplasia
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Arteritis is inflammation of the walls of arteries, usually as a result of infection or
auto-immune response.
Vasculitis is a general term for a group of diseases that feature inflammation of
the blood vessels. Each of these diseases is defined by characteristic distributions of
blood vessel involvement, patterns of organ involvement, and laboratory test
abnormalities.
Fibromuscular dysplasia (FMD) is a condition in which at least one of your
arteries has an abnormal cluster of cells growing in the artery wall. This cluster causes the
artery to narrow, which can cause damage to the organs that receive blood through the
narrowed artery.
• Vesicoureteral reflux
It refers to a condition in which urine flows from the bladder, back up the ureter,
and back into the kidneys.
• Problems of the joints or muscles that require regular use of anti-inflammatory
medications
• Family history of kidney disease
F. TESTS AND DIAGNOSIS
Chronic kidney disease usually causes no symptoms in its early stages. Only lab tests can
detect any developing problems. Anyone at increased risk for chronic kidney disease should be
routinely tested for development of this disease.
URINE TESTS
•
UrinalysisAnalysis of the urine affords enormous insight into the function of the
kidneys. The first step in urinalysis is doing a dipstick test. The dipstick has
reagents that check the urine for the presence of various normal and abnormal
constituents including protein. Then, the urine is examined under a microscope to
look for red and white blood cells, and the presence of casts and crystals.
Only minimal quantities of albumin (protein) are present in urine
normally. A positive result on a dipstick test for protein is abnormal. More
sensitive than a dipstick test for protein is a laboratory estimation of the urine
albumin (protein) and creatinine in the urine.
• Twenty-four-hour urine tests
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This test requires you to collect all of your urine for 24 consecutive hours.
The urine may be analyzed for protein and waste products (urea, nitrogen, and
creatinine). The presence of protein in the urine indicates kidney damage. The
amount of creatinine and urea excreted in the urine can be used to calculate the
level of kidney function and the glomerular filtration rate (GFR).
• Glomerular filtration rate (GFR)
The GFR is a standard means of expressing overall kidney function. As
kidney disease progresses, GFR falls. The normal GFR is about 100-140 mL/min
in men and 85-115 mL/min in women. It decreases in most people with age. The
GFR may be calculated from the amount of waste products in the 24-hour urine or
by using special markers administered intravenously. Patients are divided into
five stages of chronic kidney disease based on their GFR.
BLOOD TESTS
• Creatinine and urea (BUN) in the blood
Blood urea nitrogen and serum creatinine are the most commonly used
blood tests to screen for, and monitor renal disease. Creatinine is a breakdown
product of normal muscle breakdown. Urea is the waste product of breakdown of
protein. The level of these substances rises in the blood as kidney function
worsens.
• Estimated GFR (eGFR)
This may calculate an estimated GFR using the information from your
blood work. It is important to be aware of your estimated GFR and stage of
chronic kidney disease. Physicians uses your stage of kidney disease to
recommend additional testing and suggestions on management.
•Electrolyte levels and acid-base balance
Kidney dysfunction causes imbalances in electrolytes, especially
potassium, phosphorus, and calcium. High potassium (hyperkalemia) is a
particular concern. The acid-base balance of the blood is usually disrupted as
well.
Decreased production of the active form of vitamin D can cause low levels
of calcium in the blood. Inability to excrete phosphorus by failing kidneys causes
its levels in the blood to rise. Testicular or ovarian hormone levels may also be
abnormal.
• Blood cell counts
Kidney disease disrupts blood cell production and shortens the survival of
red cells, the red blood cell count and hemoglobin may be low (anemia). Some
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patients may also have iron deficiency due to blood loss in their gastrointestinal
system.
OTHER TESTS
• Ultrasound
Ultrasound is often used in the diagnosis of kidney disease. An ultrasound
is a noninvasive type of test. In general, kidneys are shrunken in size in chronic
kidney disease, although they may be normal or even large in size in cases caused
by adult polycystic kidney disease, diabetic nephropathy, and amyloidosis.
Ultrasound may also be used to diagnose the presence of urinary obstruction,
kidney stones and also to assess the blood flow into the kidneys.
• Biopsy
A sample of the kidney tissue is sometimes required in cases in which the
cause of the kidney disease is unclear. Usually, a biopsy can be collected with
local anesthesia only by introducing a needle through the skin into the kidney.
G. COMPLICATIONS
• Hypertension
Hypertension, or high blood pressure, is present in 80 to 85 percent of people with
CKD. This is due to a number of factors, including changes in the levels of blood
pressure hormones secreted by the kidneys and the presence of extra fluid in the blood
vessels as the kidneys lose their ability to efficiently balance fluid levels. Treatment
begins with an ACE inhibitor.
• Volume overload
Patients with CKD often develop fluid overload, which can lead to hypertensionand edema. Treatment of volume overload often requires a low salt diet.
• Anemia
Patients with CKD are at risk for anemia, or low red blood cell counts. This is
largely due to reduced production of a substance called erythropoietin by the kidneys.
Erythropoietin stimulates the body to make red blood cells, the critical oxygen-carrying
cells in the blood. When anemia occurs, oxygen delivery to the tissues falls below
normal, which can lead to fatigue and other complications.
Selected patients can be treated with drugs that stimulate red blood cell
production. In some cases, iron supplements are also prescribed.
• High potassium (hyperkalemia)
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Some patients with CKD develop a high blood potassium level, which can
interfere with normal cell function. Measures to prevent high potassium may also be
recommended, including a low potassium diet and avoiding medicines that raise
potassium levels.
• Acidosis
Patients with CKD can develop a condition known as acidosis, which means that
the blood is too acidic. Without treatment, acidosis can worsen other complications of
CKD, such as bone disease or loss of muscle mass in the body. Treatment usually
includes use of sodium bicarbonate.
• High phosphate (hyperphosphatemia)
If the phosphate balance is disturbed by CKD, bone regeneration is adversely
affected. Early in the course of CKD, the body begins to retain phosphate. As the disease
progresses and GFR declines significantly, high blood phosphate levels can develop. This
is usually treated with medicines that bind dietary phosphate in the gastrointestinal tract.
Dietary phosphate restrictions are also recommended.
• Bone disease
Progressive kidney dysfunction is associated with a number of abnormalities that
adversely affect bone. These include elevated phosphate and parathyroid hormone levels
and decreased calcium and vitamin D levels.
A person with CKD who develops bone disease or elevated phosphate is usually
treated with multiple medicines and supplements that attempt to correct some of these
abnormalities.
• Hyperlipidemia
Abnormal fat metabolism is common in patients with kidney disease. The most
common problem is an abnormally elevated blood triglyceride levels. High triglycerides
have been associated with an increased risk of coronary artery disease, which can lead toheart attack. The risk of death, particularly due to cardiovascular disease, is much higher
in people with CKD than the risk of eventually needing dialysis or kidney transplantation.
• Malnutrition
Malnutrition is common in people with advanced CKD because of loss of appetite
and decreased food intake, decreased absorption of food from the intestines, and acidosis.
The level of malnutrition can be determined by measuring a patient's weight and the level
of albumin in the blood; low albumin levels are one sign of malnutrition.
• Bleeding
An increased risk of bleeding develops in patients with very advanced or "end
stage" CKD as a result of impaired platelet function. Platelets are a critical component of
the blood clotting mechanism. No treatment is needed in patients without excessive
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bleeding. Medicines may be given to counter the platelet dysfunction if there is excessive
bleeding, or if the patient needs to undergo surgery or an invasive medical procedure.
• Sexual function
Men and women with advanced CKD often have significant difficulties with
sexual and reproductive function. Over 50 percent of men with end-stage renal disease
have difficulties with erection and decreased sex drive. Women often have disturbances
in the menstrual cycle and fertility, usually leading to a stop in menstrual periods.
Decreased sex drive may also occur in women. Patients should discuss any changes in
sexual function with their healthcare provider because medications or other treatments
may be effective.
• Pregnancy
The risk that pregnancy will worsen kidney function, or that decreased kidney
function will interfere with pregnancy depends upon a number of factors. A woman with
mild to moderate CKD who is considering becoming pregnant should discuss the possible
risks with her nephrologist and obstetrical provider before trying to conceive.
Pregnancy is not recommended for women with end-stage kidney disease due to
the increased risk of miscarriage, premature delivery, worsened kidney function, and
preeclampsia. A woman who undergoes successful renal transplantation has a reduced
risk of these complications.
H. TREATMENT
• Protein restriction
Decreasing protein intake may slow the progression of chronic kidney disease. A
dietitian can help to determine the appropriate amount of protein for the patient.
•Salt restriction
Limit to 4-6 grams a day to avoid fluid retention and help control high blood
pressure.
• Fluid intake
Excessive water intake does not help prevent kidney disease. In fact doctors may
recommend restriction of water intake.
• Potassium restriction
This is necessary in advanced kidney disease because the kidneys are unable toremove potassium. High levels of potassium can cause abnormal heart rhythms.
Examples of foods high in potassium include bananas, oranges, nuts, and potatoes.
• Phosphorus restriction
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Decreasing phosphorus intake is recommended to protect bones. Eggs, beans, cola
drinks, and dairy products are examples of foods high in phosphorus.
In chronic kidney disease, several medications can be toxic to the kidneys and may need
to be avoided or given in adjusted doses. Among over-the-counter medications, the following
need to be avoided or used with caution:
• Certain analgesics - Aspirin; nonsteroidal anti-inflammatory drugs
• Fleets or phosphosoda enemas because of their high content of phosphorus
• Laxatives and antacids containing magnesium and aluminum such as Milk of Magnesia
and Mylanta
• Ulcer medication H2-receptor antagonists
• Decongestants especially if you have high blood pressure
• Alka Seltzer because contains a lot of salt
• Herbal medications
MEDICAL TREATMENT
There is no cure for chronic kidney disease. The four goals of therapy are as follows:
1. To slow the progression of disease
2. To treat underlying causes and contributing factors
3. To treat complications of disease
4. To replace lost kidney function
Strategies for slowing progression and treating conditions underlying chronic kidney
disease include the following:
• Control of blood glucose
Maintaining good control of diabetes is critical. People with diabetes who do not
control their blood glucose have a much higher risk of all complications of diabetes,
including chronic kidney disease.
• Control of high blood pressure
This also slows progression of chronic kidney disease. It is recommended to keep
your blood pressure below 130/80 mm Hg if you have kidney disease. It is often useful to
monitor blood pressure at home. Blood pressure medications known as angiotensin
converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) have special benefit in protecting the kidneys.
• Diet
Diet control is essential to slowing progression of chronic kidney disease and
should be done in close consultation with your health care provider and a dietitian.
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The complications of chronic kidney disease may require medical treatment.
• Fluid retention can be treated with any of a number of diuretic medications, which
remove excess water from the body. However, these drugs are not suitable for all
patients.
• Anemia can be treated with erythropoiesis stimulating agents. Erythropoiesis stimulating
agents are a group of drugs that replace the deficiency of erythropoietin, which is
normally produced by healthy kidneys.
• Bone disease develops in patients due to an inability to excrete phosphorus and a failure
to form activated Vitamin D. In such circumstances, doctors may prescribe drugs binding
phosphorus in the gut, and may prescribe active forms of vitamin D.
• Acidosis may develop with kidney disease. The acidosis may cause breakdown of
proteins, inflammation and bone disease.
DIALYSIS
In end-stage renal disease, kidney functions can be replaced only by dialysis or by kidney
transplantation. There are two types of dialysis 1) hemodialysis and 2) peritoneal dialysis.
1. Hemodialysis
Hemodialysis involves circulation of blood through a filter on a dialysis machine.
Blood is cleansed of waste products and excess water. The acid levels and the
concentration of various minerals such as sodium and potassium in the blood are
normalized. The blood is then returned to the body.
• Long-term dialysis requires access to a blood vessel so that the machine has a
way to remove and return blood to the body. This may be in the form of adialysis catheter or an arteriovenous fistula or graft.
• A catheter may be either temporary or permanent. These catheters are either
placed in the neck or the groin into a large blood vessel. These catheters are
prone to infection and may also cause blood vessels to clot or narrow.
• The preferred access for hemodialysis is an arteriovenous fistula wherein an
artery is directly joined to a vein. The vein takes two to four months to enlarge
and mature before it can be used for dialysis. Once matured, two needles are
placed into the vein for dialysis. One needle is used to draw blood and run
through the dialysis machine. The second needle is to return the cleansed
blood.
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• An arteriovenous graft is placed in patients who have small veins or in whom
a fistula has failed to develop. The graft is made of artificial material and the
dialysis needles are inserted into the graft directly.
• These venous access devices usually can be placed with local anesthesia on an
outpatient basis.
• Hemodialysis typically takes three to five hours and is needed three times a
week.
• A dialysis center is needed for hemodialysis.
• Home hemodialysis is possible in some situations. A care partner is needed to
assist you with the dialysis treatments. A family member or close friend are
the usual options.
2. Peritoneal dialysis
Peritoneal dialysis utilizes the lining membrane (peritoneum) of the abdomen as a
filter to clean blood and remove excess fluid. A catheter is implanted into the abdomen
by a minor surgical procedure. Peritoneal dialysis may be performed manually or by
using a machine.
• About 2 to 3 liters of dialysis fluid are infused into the abdominal cavity
through this catheter. This fluid contains substances that pull wastes and
excess water out of neighboring tissues.
• The fluid is allowed to dwell for two to several hours before being drained,
taking the unwanted wastes and water with it.
• The fluid typically needs to be exchanged four to five times a day.
• Peritoneal dialysis offers much more freedom compared to hemodialysis since
patients do not need to come to a dialysis center for their treatment. They can
carry out many of your usual activities while undergoing this treatment.
TRANSPLANTATION
Kidney transplantation offers the best outcomes and the best quality of life. Transplanted
kidneys may come from living related donors, living unrelated donors, or people who have died
of other causes (cadaveric donors). In people with type I diabetes, a combined kidney-pancreastransplant is often a better option.
However, not everyone is a candidate for kidney transplant. Patients need to undergo
extensive testing to ensure their suitability for transplantation. Also, there is a shortage of organs
for transplantation, requiring patients to wait months to years before getting a transplant.
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A person who needs a kidney transplant undergoes several tests to identify characteristics
of his or her immune system. The recipient can accept only a kidney that comes from a donor
who matches certain of his or her characteristics. The more similar the donor is in these
characteristics, the greater the chance of long-term success of the transplant. Transplants from a
living related donor generally have the best results.
Transplant surgery is a major procedure and generally requires four to seven days in the
hospital. All transplant recipients require lifelong immunosuppressant medications to prevent
their bodies from rejecting the new kidney. Immunosuppressant medications require careful
monitoring of blood levels and increase the risk of infection as well as some types of cancer .
PREVENTION
Chronic kidney disease cannot be prevented in most situations. You may be able to
protect your kidneys from damage, or slow the progression of the disease by controlling your
underlying conditions.
• Kidney disease is usually advanced by the time symptoms appear. If someone is at high
risk of developing chronic kidney disease, it is better to inquire for diagnostic
examinations and screening.
• If a person has a chronic condition such as diabetes, high blood pressure, or high
cholesterol, follow the treatment recommendations of the physician. Monitoring and
aggressive treatment of the diseases is advised.
• Avoid exposure to drugs especially NSAIDs (nonsteroidal anti-inflammatory drugs),
chemicals, and other toxic substances as much as possible.
ANATOMY AND PHYSIOLOGY
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The kidneys are the primary organs of the urinary system in vertebrates. The kidneys
filter the blood, remove the wastes, and excrete the wastes in the urine. About 1,300 milliliters of
blood flow through the kidneys each minute (about 400 gallons a day). From this blood the
Malphigian corpuscles extract about 170 liters of filtrate a day. As this fluid passes down the
uriniferous tubules it is almost all reabsorbed. Only about 1.5 liters are left in the tubules to carry
away the waste products.
The whole blood supply passes through the kidneys every 5 minutes, ensuring that waste
materials don't build up. The renal artery carries blood to the kidney, while the renal vein carries
blood, now with much lower concentrations of urea and mineral ions, away from the kidney. The
urine formed passes down the ureter to the bladder.
LOCATION, SHAPE, AND SIZE OF THE KIDNEYS
The kidneys are paired, bean-shaped organs. Adult human kidneys are approximately 12
cm long, 6 cm wide and 3 cm thick. They are situated in the abdominal cavity, just below the rib-cage, one on either side of the spine. More specifically, they lie between the twelfth thoracic and
third lumbar vertebrae.
The right kidney usually is slightly lower than the left because the liver displaces it
downward.
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The kidneys, protected by the lower ribs, lie in shallow depressions against the posterior
abdominal wall and behind the parietal peritoneum. This means they are retroperitoneal.
Each kidney is held in place by connective tissue, called renal fascia, and is surrounded
by a thick layer of adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous,
connective tissue known as the renal capsule closely envelopes each kidney and provides support
for the soft tissue that is inside.
STRUCTURE OF THE KIDNEY
Each kidney has an indentation, called the hilum, on the medial side. The hilum leads to a
large cavity, called the renal sinus, within the kidney. The ureter and renal vein leave the kidney,
and the renal artery enters the kidney at the hilum.
The outer, reddish region, next to the capsule, is the renal cortex. This surrounds a darker
reddish-brown region called the renal medulla. The renal medulla consists of a series of renal
pyramids, which appear striated because they contain straight tubular structures and blood
vessels. The wide bases of the pyramids are adjacent to the cortex and the pointed ends, called
renal papillae, are directed toward the center of the kidney. Portions of the renal cortex extend
into the spaces between adjacent pyramids to form renal columns. The cortex and medulla make
up the parenchyma, or functional tissue, of the kidney. The central region of the kidney contains
the renal pelvis, which is located in the renal sinus and is continuous with the ureter. The renal
pelvis is a large cavity that collects the urine as it is produced. The periphery of the renal pelvis
is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae of
each pyramid and collects urine from that pyramid. Several minor calyces converge to form a
major calyx. From the major calyces the urine flows into the renal pelvis and from there into the
ureter.
Each kidney contains over a million functional units, called nephrons, in the parenchyma
(cortex and medulla). The nephrons make up the bulk of the kidney tissue and join up with larger
collecting tubes that eventually form the main urine-carrying duct – the ureter.
FUNCTIONS OF THE KIDNEY
The work of the kidneys is much more than just the removal of waste, however. Other
functions of the kidneys include: Helping control the amount of water lost to the outside world –
most important in land animals.
• Helping regulate the of the blood and the general balance of ions in the blood, and hence
in the body fluid as a whole.
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• Conserving essential substances such as glucose and amino acids.
ANATOMY AND PHYSIOLOGY OF THE NEPHRON
The blind end of each nephron, or kidney tubule, lies in the cortex and may be likened to
a champagne glass, the walls and stem of which are hollow and one cell thick. The bowl of the
tubule is known as the Bowman's capsule (or the glomerular capsule). It surrounds an elaborate
knot of blood capillaries – tiny branches of the renal artery – called the glomerulus. Each
Bowman's capsule and glomerulus together form the Malpighian body.
The hollow stem of the champagne glass is the upper part of the tubule. This descendsinto the medulla where it narrows before turning upwards and ascending back into the cortex,
increasing in diameter again. The thin portion of the tube is known as the loop of Henle and is
primarily concerned with the absorption of water. The ascending limb of the tubule joins a
collecting duct which joins with others before eventually discharging its urine into the ureter.
In effect, each Bowman's capsule is a tiny filter. Blood containing waste substances,
proteins, sugars, etc., is forced to the kidneys by the pumping action of the heart. Under pressure,
a solution is driven out of the capillaries of the glomerulus through the walls of the capsule into
its hollow interior. The solution in the capsule is blood plasma minus the large molecules. These
are two big to pass through the capillary wall.
From the capsule the fluid passes along the tubule. Many of the substances in it are
absorbed through the tubule wall into the blood capillaries that envelop this, so that it gradually
becomes more concentrated. Organic molecules such as some amino acids and glucose, some
salts and water are absorbed in the descending or proximal limb of the tubule, while more water
and salts are absorbed in the ascending or distal limb. Certain poisonous or toxic substances that
have been rendered harmless are released into the urine by the tubules, together with potassium
and hydrogen. Measurements of the amounts of various substances present in the blood and in
the urine show striking differences. The concentration of the principal waste substance in the
urine (urea) is normally 70 times as great as it is in the blood, yet, surprisingly enough, some
urea is reabsorbed, since a certain blood concentration is needed. Ninety times more sulfate, 9
times more potassium, and 25 times more uric acid occur in the urine than in the blood. On the
other hand no glucose, fatty substances, proteins, or bicarbonate ions normally occur in the urine,
whereas considerable quantities occur in the blood.The normal daily output of urine is between two and a half to three pints, yet it is
calculated that a total of nearly 300 pints of fluid is filtered by the kidneys during that time. They
not only reabsorb a vast volume each day; they also regulate its content so that the correct levels
of essential substances are maintained in the body fluids.
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The juxtaglomerular apparatus, which monitors blood pressure and secretes renin, is
formed from modified cells in the afferent arteriole and the ascending limb of the nephron loop.
III. CASE STUDY PROPER
A. General Data
Name: Marife Del Rosario Esquibel
Age: 30 years old
Birth date: October 3, 1979
Sex: Female
Civil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Name of Mother: Zenaida Telar
Address:Brgy. Madulao Catanauan, Quezon Province
Department: Quezon Medical Center - Internal Medicine
Bed No.: 319
Chief Complaint: Dizziness and body weakness
Initial Diagnosis: Anemia chronic disease, renal disease, body dyscrasia
Final Diagnosis: Chronic kidney disease secondary to chronic glomerulonephritis
Date of Admission: September 6, 2009
Time of Admission: 8:14pm
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Attending Physician: Dra. Yvette Panganiban Luce
Date of Discharge: September 14, 2009
Time of Discharge: 2:00pm
Case Number: 09090369
A. Physical Assessment
• General Appearance
> Conscious and coherent
> Pale in appearance
• Skin
> absence of cyanosis
> with dry skin
> cold clamming skin
> no rashes or lesions noted
> with fair skin turgor
• Initial Vital Signs and Other Anthropometric Measurements
> Temperature: 36.3°C
> Pulse Rate: 85bpm
> Respiration Rate: 16bpm
> BP: 130/80mmHg
• Head/Face
> With black and good hair distribution
> No dandruffs and scalp damage noted
> With symmetrical facial features
• Eyes
> eyebrows evenly distributed, symmetrically aligned with equal
movement
> eyelids intact, no discoloration and closes symmetrically
> With yellowish sclera
> With pale conjuctiva
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• Extremities
> No lesion noted on both extremities
> No palpable mass noted
> With slightly pale nailbeds on both upper and lower extremities
> With capillary refill time of 1-2 secs.
B. History of Present Illness
One week prior to admission the pt. had experienced episodes of dizziness and
DOB, she was confined to a primary hospital in Catanauan but does not resolved and
eventually was admitted on September 6, 2009 at Quezon Medical Center. She was
diagnosed of Chronic Kidney Disease secondary to AGN. She’s also experiencing the
abdominal pain, vomiting and nausea.
C. History of Past Illness
According to the patient, when she was still a child, she was also unable to tolerate doing
heavy activities. Other health problems that she encountered were cough and colds.
D. Familial Health History
According to the patient, they have history of diabetes mellitus ,heart stroke and
hypertension.
E. Personal and Social History:
The patient is living a simple life in a barrio together with her husband and son. She is
working in a farm. She’s fond of drinking alcohol beverages together with her neighborhood and
she also smokes.
F. Course in the Ward
• Septenber 6, 2009 (day 1)
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> Marife Esquibel, 30 years old, female/married, was admitted in Quezon
Medical Center, episodes of dizziness and DOB prior to admission.
> Her admitting doctor, Dra. Luce ordered to monitor her vital signs every
shift, to have CBC stat, urinalysis, creatinine stat, ECG,BUN.
> Her first of IVF was D503 NaCl X KVO. The medications given to her
were clonidine 75mg 1 tab SL now, amlodipine 50mg 1tab OD,
omeprazole 20mg 1 cap BID
> She was also for transfusion of 4 “u” PRBC properly type and cross match
> She was ordered to monitor vital signs every 4 hours and monitor intake
and output every shift.
• September 7, 2009 (day 2)
> The doctor ordered to continue present medications
> For possible hemodialysis and facilitate blood transfusion
> Medications ordered were NaHCO3 1 tab OD, ketosteril 600mg 2tabs TID
• September 8, 2009 (day 3)
> Dr. Luce ordered to facilitate UTZ and ordered IVF of PNSS 1L x KVO
as her 2nd bottle.
> The doctor also ordered for referral to nephro
• September 9, 2009 (day 4)
> Medication ordered were cefexime 250mg 1 cap BID, FeSO4 1 cap OD,
erypoetin 4000 “u” SQ 2 x a day and folic acid 1 tab OD
• September 10, 2009 (day 5)
> The doctor ordered to facilitate BT.
> IVF of PNSS 1L KVO was again ordered as her 3rd bottle.
•
September 11, 2009 (day 6)
> The doctor ordered to facilitate hemodialysis once with funds
> IVF of PNSS 1L x KVO was again ordered as her 4 th bottle
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• September 12, 2009
> Medication ordered were captopril 20g 1 tab SL prn for BP 140/90
> Facilitate repeat CT scan.
> IVF of PNSS 1L x KVO was again ordered as her 5 th bottle.
• September 13, 2009
> The doctor ordered referral to hemodialysis.
> HAMA
• September 14, 2009
> HAMA
G. Laboratory Analysis and Examination
September 6, 2009
Hematology
CBC RESULT NORMAL VALUE INTERPRETATION
Hemoglobin 4.5g/dl 12-15gm/dl Anemia
Hematocrit 14 vol % 30-40 vol % Anemia
WBC 5,000/cumm 5,000 – 10,000/cumm Normal
Differential Count
Neuthrophils 77 40-60% infection
Lymphocytes 35 35-40% Normal
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• Nursing Responsibilities
Assess blood values
Assess for contributing factors
Advise to perform deep breathing exercise
Maintain high back rest
Encourage to drink enough amount of water
Advise to eat foods rich in iron like meat liver and green leafy vegetables
Encourage to eat foods rich in Vitamin C like guava, oranges and suha
Stress the importance of frequent hand washing
Advise on proper personal hygiene
Encourage to have adequate rest and sleep periods
Stress the importance of strict adherence to treatment regimen
Blood Chemistry
COMPONENTS RESULT NORMAL VALUES INTERPRETATION
Na 136 mmol/L 136-146 mmol/L normal
K 4.1 mEq/L 3.5-5 mEq/L normal
September 8, 2009
Urinalysis
Components Result Normal Value Interpretation
Color Yellow Yellow Normal
Transparency Turbid Clear Abnormal
Reaction 1.0 4.8-7.8
S
pecific Gravity 7.5 1.015-1.025
• Nursing Responsibilities
Assess urinalysis values
Assess for contributing factors
Encourage to drink enough amount of water
Advise to avoid eating salty and junk foods
Advise to limit taking carbonated drinks like soft drinks
Stress the importance of frequent hand washing
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Advise on proper personal hygiene
Encourage to have adequate rest and sleep periods
Stress the importance of strict adherence to treatment regimen
Blood Chemistry
CONPONENTS RESULT NORMAL VALUES INTERPRETATION
Creatinine 27.5 0.3-1.3 Kidney is not
functioning well
•Nursing Responsibilities
Assessed for signs and symptoms of increased creatinine such as urinary
frequency.
Instructed pt. to avoid foods that are rich in salts and fats.
September 12, 2009
Hematology
CBC RESULT NORMAL VALUE INTERPRETATION
Hemoglobin 7.4g/dl 12-15gm/dl AnemiaHematocrit 22.0 vol % 30-40 vol % Anemia
WBC 8, 600/cumm 5,000 – 10,000/cumm Infection
Differential Count
Neuthrophils 75 40-60% Infection
L
ymphocytes 35 35-40% Normal
• Nursing Responsibilities
Assess blood values
Assess for contributing factors
Advise to perform deep breathing exercise
Maintain high back rest
Encourage to drink enough amount of water
Advise to eat foods rich in iron like meat liver and green leafy vegetables
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Encourage to eat foods rich in Vitamin C like guava, oranges and suha
Stress the importance of frequent hand washing
Advise on proper personal hygiene
Encourage to have adequate rest and sleep periods
Stress the importance of strict adherence to treatment regimen
September 13, 2009
Hematology
CBC RESULT NORMAL VALUE INTERPRETATION
Hem
oglobin 7.4g/dl 12-15gm/dl Anemia
Hematocrit 22.0 vol % 30-40 vol % Anemia
WBC 9,000/cumm 5,000 – 10,000/cumm Infection
Differential Count
Neuthrophils 72 40-60% Infection
Lymphocytes 36 35-40% Normal
• Nursing Responsibilities
Assess blood values
Assess for contributing factors
Advise to perform deep breathing exercise
Maintain high back rest
Encourage to drink enough amount of water
Advise to eat foods rich in iron like meat liver and green leafy vegetables
Encourage to eat foods rich in Vitamin C like guava, oranges and suha
Stress the importance of frequent hand washing
Advise on proper personal hygiene
Encourage to have adequate rest and sleep periods
Stress the importance of strict adherence to treatment regimen
EVALUATION
On September 14, 2009, the patient went home against medical advised and bought the
take home medications that were instructed by the doctor. She refused dialysis because of money
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restrictions but followed the diet instructed by the doctor. She loves to eat salty and canned
goods before but she will not take those kinds of food anymore. She has enough knowledge on
her disease and knows the consequences of what she is doing. There is no cure on her disease
and the only thing that she can do is slow the destruction of her kidney that’s why she follows all
the doctors of the doctor as long as their financial capacity can.
Through the nurse and client interaction, we learned how to take care of a patient with
chronic kidney disease and able to teach and explain to her the proper way of taking care of
herself. The students were able to trace and know how this disease starts and able to interpret
laboratory finding and studies and relate it to the cause of the disease and how it develops.