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EMILIO AGUINALDO COLLEGE

Congressional East Ave., Burol Main,


City of Dasmarias, Cavite
(046) 416341 to 42

A Case Study on End Stage Renal


Disease secondary to Diabetic
Nephropathy
In partial fulfillment of the requirements in NCM106 Care of Clients with Problem
in Cellular Aberration, Acute Biologic Crisis including Emergency and Disaster
Nursing
Submitted By:
CAL, Joan S.
CUBILLA, Princess Claudine L.
GALBAN, Lenecar I.
MAGLUPAY, Rhaizza Belle E.
SAMSON, Apple Grace N.

Submitted To:
Ms. Obdulia M. Almarez, RN, MAEd, MAN
Clinical Instructor
SEPTEMBER 2016

I. PATIENT PROFILE
Patient Name: V.D

Date of Interview: September 01, 2016

Address: Bacoor, Cavite

Primary Informant: Patient V.D.

Age: 54 years old

Secondary Informant: V.Ds youngest son

Gender: Female

Other Data Sources: Patients Chart

Educational Status: College Level


Religion: Roman Catholic
Civil Status: Married
Occupation: None
II. REASON FOR SEEKING HEALTH CARE
During admission, VDs son claimed that her mother was scheduled for her 15 th
Hemodialysis session. He also claimed that her mother gained weight and having difficulty of
breathing.
III. HISTORY OF PRESENT ILLNESS
Two months prior to consultation Patient VD experienced body weakness, difficulty of
breathing and theres a time wherein she experienced syncope. As Patient VD verbalized she
feels extreme fatigue, and always feels cold even the temperature is warm. This is the reason
why her children decided to seek medical care and bring their mother to EACMC. The attending
physician advised them that their mother should undergo different laboratory studies and found
out that Patient VD has End Stage Renal Disease and Hypoparathyroidism.

IV. PAST MEDICAL HISTORY


Patient VD verbalized that she has been hospitalized for several times before. Her first
hospitalization was on 2005, wherein patient VD was diagnosed with right and left ovarian
myoma and she claimed that she undergone Total Abdominal Hysterectomy Bilateral SalphingoOoperectomy. She verbalized that after her operation that was the time she felt weak and started
to feel changes in her activities of daily living.
It was 2005 when Patient VD was also diagnosed with Diabetes Mellitus Type 2
(Lifestyle DM) and Hypertension. She claimed that when she was diagnosed with DM and HPN
she follows all of her doctors regimen like taking her anti-hypertensive (Amlodipine) drugs and
her oral hypoglycemic drugs (Metformin), but she seldom exercise and still fond of consuming
foods with high glucose content like soda, rice cake and fast-foods.
December 2015, patient VD was rushed again to the hospital because during the morning
of the same day, she fainted with no apparent reasons. When the doctor assessed her and ordered
doctor ordered transfusion of 2 packs of whole blood in order to correct her hemoglobin and
hematocrit level.
March 2016, patient VD was admitted at EACMC-C due to difficulty of breathing,
bipedal edema, difficulty in ambulating, and extreme fatigue. Based from her laboratory studies
her attending physician found out that she has Pulmonary congestion secondary to End Stage
Renal Disease but VDs son claimed that even his mother was diagnosed with ESRD, the doctor
did not recommend a Hemodialysis treatment to his mother immediately, but instead she was
given medications for her condition as an alternative solution for her kidney failure.
July 2016, patient VD was admitted at EACMC-C due to extreme fatigue, difficulty
urinating, persistent cough and difficulty of breathing. Based from her laboratory studies, her
BUN and Creatinine Clearance was elevated BUN: 35mg/dL, CREA: 708mg/dL and based from
her Thyroid function studies she has hypothyroidism.. This is the time where her attending
physician advised her to have her Hemodialysis treatment. The night of that day, she had her 1 st
hemodialysis treatment with a Subclavian fistula as access to her Hemodialysis treatment.

Patient VD has no known allergies to food. In 2008, they found out that she has allergy to
Amlodipine Besylate because she experienced itchiness and dry skin. Her attending physician
changed her anti-hypertensive medication from Amlodipine Besylate to Lacarnidipine. As
Patient VD claimed, she could not remember if she received any vaccination before. She claimed
that she had Mumps, Chicken Pox, Measles, and Rubella before when she was still young.
V. DEVELOPMENTAL THEORY
A. SIGMUND FREUD PSYCHOSEXUAL THEORY
Freud Psychosexual Development theory emphasized that on the fifth stage in the
Genital Stage that spans Puberty throughout Adult life and thus represents most of a persons
life; Its purpose is the psychological detachment and independence from the parents Patient VD
started to live without her parents after getting married at the age of 24. She was blessed with 5
children but after 20years of getting married, she and her husband decided to separate. With
regards to her current relationship, she is with her youngest son taking care of her.
B. ERIK ERIKSONs PSYCHOSOCIAL THEORY
A persons social view of self is more important than instinctual drives in determining
behaviors that allows for a more optimistic view of the possible human growth according to this
theory. He describes 8 stages.
Patient VD whose age is 54years old falls under Generativity vs. Stagnation. The adult
stage of generativity has broad application to family relationships, work and society. Patient VD
is separated with her husband 10years ago. Patient VD also verbalized Hindi ako masyado
lumalabas ng bahay at nakikihalubilo sa iba kahit sa kapit bahay She is living with her
youngest son who was the one taking care of her. With the situation mentioned above Patient VD
develops Stagnation.

VI. GORDONS FUNCTCIONAL HEALTH PATTERN


A. HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN
Patient VD verbalized that before her Hemodialysis treatment she feels weak and tired.
She claimed that she has monthly consultation to her attending physician and laboratory work
ups every 3months. Before she was diagnosed with ESRD she claimed that she has sedentary
lifestyle, she consumes a lot of food with high glucose content, she seldom exercise because as
she verbalized Hindi ako nagdi-diet dati hindi din ako nage-exercise, kasi nainom naman ako
ng gamot Before when she experiences minor illness such as headache, fever or flu she does
not consult her doctor instead she take over the counter medications.
Patient VD claimed that when her Hemodialysis treatment started she feels weaker
compared before. She was not able to walk because of her bipedal edema. She claimed that her
doctor gave her restrictions such as to decrease her glucose, sodium, potassium, intake. She has
also fluid restriction of 1 liter of fluid a day. She verbalized that she has to take medications as
maintenance for her illness such as Lercanidipine and Clonidine for her Hypertension, Trajenta
for her Diabetes Mellitus, Levothyroxine for her Hypothyroidism. During the exposure Patient
VD was been carefully monitored specifically her DM and electrolytes.
B. NUTRITIONAL AND METABOLIC PATTERN
Patient VD admitted that before she was diagnosed with DM and Hypertension she was
consuming large amount of foods with high glucose content, shes fond of eating rice cakes,
fruits, and fast-foods. She claimed that she seldom drink water instead she consumes carbonated
beverages. Patient VDs weight is 73kilograms and height 53. She has a BMI of 23.49 this is
classified as normal.
As Patient VD was having her Hemodialysis treatment she has particular restrictions with
regards to her food intake. Her attending physician advised her to limit her intake of foods
having high glucose, sodium, potassium and fats. She has also fluid restriction of 1 liter of fluid a
day. She verbalized that she started to have a reducing diet wherein she only consumes half cup
of rice per meal, fish as her viand and limits her fluid intake. Patient VD claimed that it is hard to
limit her fluid intake but it is harder to control the foods she was allowed to eat.

Patient VD verbalized Yung mga anak ko areglado sa pag-control ng pagkain ko, minsan
nahihirapan na ako
C. ELIMINATION PATTERN
Patient VD verbalized that she has having difficulty in voiding, there was a time wherein
her urine has scant amount of blood. But she claimed that they just ignore it and does not consult
a physician regarding the incidence. As she claimed her urine output has the same amount as
same as her fluid intake. Usually, 800 cc to 1000 cc per day clear in color and without foul odor.
Patient VD verbalized that she defecates twice a day during early morning and in the
afternoon. As she claimed her feces was not odorous, semi-solid in consistency and brown in
color. Shes not having difficulty defecating.
D. ACTIVITY-EXERCISE PATTERN
As Patient VD claimed she seldom exercise even before when she was still not diagnosed
with her illnesses. She claimed that before, she has a lot of things to do in their house that is why
exercising is not a priority and she believes that by doing household chores it is a form of
exercise. She claimed that when she was diagnosed with DM her doctor advised her to do
minimum amount of exercise such as brisk walking or having a jog everyday but she doesnt
follow the order.
Patient VDs son verbalized that as of today her mother is having difficulty in
ambulating, therefore most of the time, her mother is just sitting in their house, watching TV and
seldom stands up. She just stand up when VD will eat and has to go to the restroom.
Majority of patient VDs activities of daily living require assistance from bathing,
dressing, toileting, transferring, and feeding. Patient VD is completely dependent.
E. SLEEP-REST PATTERN
Patient VD claimed that she have trouble sleeping continuously at night because she feels
pain and that she also have difficulty in breathing, that makes her sleep pattern be interrupted and
be limited to few hours of sleep for the entire day.

F. COGNITIVE-PERCEPTUAL PATTERN
Patient VD have no problem with her sense of smell but her eyesight is slightly impaired
due to her past history of glaucoma in the year 2013. Patient VD was also observed to have
difficulty hearing different sounds.
G. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
Upon assessment, patient VD verbalized that she feels weak and that she thinks she wont
be able to feel better soon. Patient also verbalized that, Simula nung nag dialysis ako, lalo
akong humina.
H. ROLE-RELATIONSHIP PATTERN
Patient VD admitted that she is already separated to her husband for already 10 years
now. She was left with their 5 children, 4 sons 1 daughter. But she is only living with their
youngest who is still studying. She also said that she rarely communicate and participate to
different community activity.
I. SEXUALITY- REPRODUCTIVE PATTERN
Patient verbalizes that her menarche happened when she was just 11 years old. She
admitted that her menstrual duration lasts for only 3 days. During her younger years whe was
sexually active that leads her to gravida 5. Year 2005, she was diagnosed with left and right
myoma, with idiopathic cause, and she claimed that shes been operated for TAHBSO.
J. COPING-STRESS TOLERANCE PATTERN
Patient VDs coping is absent because she, herself, believes that she is severely sick and
that her disease will not be cured nor be alleviated anymore. She doesnt follow her diet
restrictions for she believes that Okay lang naman kumain ng bawal kasi may gamot naman
ako

K. VALUE-BELIEF PATTERN
Patient VD states that she is a Roman Catholic but she does not attend mass regularly.
Though she practices praying, still, she doesnt believe that the Almighty can help her current
condition.
VII. PHYSICAL EXAMINATION
A. GENERAL INFORMATION
Patient VD started to gain weight two months ago. She feels really weak and ill. Even
when at rest she feels tired. She complains of flank pain, bipedal edema and difficulty of
breathing.
B. MENTAL ACUITY
During assessment Patient VD was oriented, conscious and coherent. She was able to
respond to the student nurses appropriately.
C. SKIN
Upon assessing Patient VD, she has dry and itchy skin. She has no lesions, bruise or
bleeding. The only complaint gathered from her is that her skin was always itchy. Upon
assessment student nurses noticed that she has dry, flaky skin. Her skin itchiness was caused by
increased phosphorus level in her blood. We observed that she has non pitting bipedal edema.
D. HEAD
Patient VD has symmetric, round head. Her face is symmetrical with oval in appearance.
Patient VD has soft, silky hair and no signs of alopecia.
E. EENT (EYES, EARS, NOSE&THROAT)
Patient VD has pale palpebral conjunctiva, her cornea has some opacities. Her pupils was
equal, round, reactive to light and accommodation. She admitted that she has glaucoma. Patient
VDs ears are equal in size and has similar appearance. No presence of cerumen. Patient VD has
difficulty in hearing. Upon assessing VDs nose it was clean and free from any obstruction. She

has no episodes of epistaxis. Patient VD has no episodes of bleeding gums, toothaches or sore
throat. Patient VD uses dentures.
F. CHEST AND BREAST
Upon assessing patient VDs chest she has crackles predominantly during inspiration. She
has a Respiratory Rate 34cpm. She is experiencing difficulty of breathing. Patient VD has a slow
bounding pulse. Her pulse rate was 60bpm. The patient refused to assess her breast.
G. GASTRO-INTESTINAL TRACT
Patient VD has a dull abdominal sound. Ascites is present. She has an abdominal girth of
44inches. She has no reported incidence of constipation, change in BM, or Heart burn.
H. GENITO-URINARY TRACT
Patient VD has flank pain, dysuria and urine retention. She was not able to urinate the
same amount of fluid she takes.
I. EXTREMITIES
Patient VD has a non pitting bipedal edema, upon assessment she has joint pain and
muscle stiffness. She has no injuries or lesion.
J. NEUROLOGICAL STATUS
Patient VD experiences numbness and tingling sensation specifically on her lower
extremities. She has an episode of fainting last March 2016. She can still remember past events
clearly.

VIII. ANATOMY AND PHYSIOLOGY


The kidneys are paired retroperitoneal structures that are normally located between the
transverse processes of T12-L3 vertebrae, with the left kidney typically somewhat more superior
in position than the right. The upper poles are normally oriented more medially and posteriorly
than the lower poles.
The kidneys serve important functions, including filtration and excretion of metabolic
waste products (urea and ammonium); regulation of necessary electrolytes, fluid, and acid-base
balance; and stimulation of red blood cell production. They also serve to regulate blood pressure
via the renin-angiotensin-aldosterone system, controlling reabsorption of water and maintaining
intravascular volume. The kidneys also reabsorb glucose and amino acids and have hormonal
functions via erythropoietin, calcitriol, and vitamin D activation.

IX. PATHOPHYSIOLOGY

PREDISPOSING FACTORS

PRECIPITATING FACTORS

-Age

-Diet: consuming foods with high glucose


content

-Family History

-Sedentary Lifestyle

-Genetics

-Compliance: not following medical


regimen

Exhaustion of beta cells occur

Altered pancreatic insulin production

Decreased insulin production

Decreased absorption of glucose by cells

Glucose is unable to enter cells

Glucose remains in the blood stream

Increase serum glucose level

Decreased tissue
perfusion of the
kidney

Sluggish flow
of blood

Increase serum
osmolarity

Impaired
delivery of
blood
components

Increase blood
viscosity

Impair
removal of
waste

Decreased
blood flow to
the organs and
extremities

Impaired
removal of
waste from
the blood

Inadequate
inflammatory
response

Failure to
initiate
erythropoie
tin

RBC
production
decreased

Hyperglycemia

Decrease
osmotic
pressure in
blood

Increase
Glucose
concentratio
n in urine

Decrease
Glucose
intake of
cells

Water from
cell towards
the blood

Decreased
reabsorption
of glucose in
renal tubule

Decrease
ATP
production

Dehydration

Decrease
osmotic
pressure

Decrease
Energy for
normal cells
function

Microorganism
would enter
the body at any
route

Infection
occurs

Decrease
perfusion in
nerves

Nerve hypoxia

WBC (11,820)
Eosinophils 2 %
Segmental
demyelinizatio
n

Nerve Damage

Excessive glucose is
converted into
SORBITOL which
accumulate in nerves

Sorbitol
impairs motor
nerve
conduction

Glucose
level
exceeds
renal
threshold

Impaired
Renal
function

Increase
permeability
of the renal
cell wall

Filtration of
macrocells
and particles

Glycosuria

RBC 2.82

Stimulation
of
osmorecepto
rs

Decrease
water
reabsorption

Cells
starvation
occurs

THIRST

Increased
Urine output

Stimulation
of the
hunger
mechanism

Polydipsia

Polyuria

Hunger
occurs

Polyphagia

Parasthesia, Numbness

Decreased Pulse Rate


(60bpm)

TYPE 2
DIABETES MELLITUS
Increase
BUN and
Creatinine

End Stage Renal DIsease

Abnormal
Calcium and
pH

Edema

Hypoparathyroi
dism

Signs and
Symptoms

Pulmonary
Congestion

Decreased
calcium level
(2.82)
Cold intolerance
Tremors
Syncope

X. LABORATORY

Component
WBC
Hemoglobin

Result
11, 820 (H)
8.44 (L)

Normal values
5000 10,000 cumm
M: 13.5 -18 gms

Interpretation
Infection
Few
RBC,

F: 12- 16 gms

Hypothyroidism,
Chronic

Hematocrit

Segmenters
Lymphocytes
Monocyte

24.51 (L)

52
30
16 (L)

Kidney

M: 40- 48gms

Disease
Destruction of red

F: 37-45 gms

blood

40- 60 %
20- 40%
2- 10%

Overhydration
Within normal values
Within normal values
Autoimmune
disorder,

cells,

blood

disorder.
Might be a sign of
infection, or a heart
Eosinophils
Basophil
Platelet count

2
0
Adequate
count

0-5%
0-2 %
platelet

complication
Within normal values
Within normal values

Red Blood Cell

2.82 (L)

M: 4.6 -6.5 mil/ cumm

Chronic

F: 4.3 5.5 mil/cumm

disease,

kidney

Hypothyroidism,
MCV
MCH
MCHC

86.95
29.93
34.42

82 -98%
28- 32%
32- 38%

anemia.
Within normal values
Within normal values
Within normal values

Test
Ionized calcium

Result
1.04 (L)

Normal Values
1.13- 1.32 mmol/L

Interpretation
Hypocalcemia, Water

135- 148 mmol/L

intoxication
Hyponatremia, Water

3.5- 5 mmol/ L

intoxication
Within normal values

Sodium
Potassium

129.3 (L)
4.61

XII. NURSING MANAGEMENT


LIST OF PRIORITIZED NURSING PROBLEMS
PRIORITIZATION
Problem No. 1
Problem No. 2
Problem No. 3
Problem No.4
Problem No. 5

XIV. DISCHARGE PLANNING

NURSING PROBLEM
Ineffective breathing pattern
Fluid volume excess
Impaired Skin Integrity
High risk for decreased cardiac output
Risk for Infection

DATE IDENTIFIED
September 1, 2016
September 1, 2016
September 1, 2016
September 1, 2016
September 1, 2016

M: Medication:
Lecarnidipine, as one of her home medication must be taken once a day with a dosage of 20mg/ tab. This is taken to treat her
hypertension. As well as, Carvedilol, an anti-hypertensive agent, must be taken once a day with 6.25 mg/ tab. Another type of
hypertensive medication is Clonidine which should be taken thrice a day, 75 mcg/ tab. She is also prescribed with Tradjenta, to treat
her Type II Diabetes. A 500 mg/ tab of Calcium carbonate is also prescribed three times a day. Because of her hypoparathyroidism, she
is prescribed to take Levothyroxine 25mcg + 12.5 mg once a day. Patient VD must also take her diuretic medication which is
Furosemide, 40mg/ tab twice daily, to treat her edema.
E: Exercise:
Since the patients physical mobility is limited, she cant perform strenuous exercises, instead her attending physician advised her to
use a stress ball to exercise her fistula for it to be used as an access during her hemodialysis.
T: Treatment:
The patient is recommended to have her dialysis three times a week.
H: Health Teaching:
The patient was advised to comply with her home medication. She was also advised to follow the prescribed diet and exercise given to
her by her attending physician.
O: Outpatient follow up:
Her attending physician advised her to have monthly consultation and laboratory work-ups.
D: Diet

The patient is restricted to 1L of fluid a day, she is also instructed to avoid foods that contains large amount of sodium, potassium and
glucose. The patient was also advised to limit her cholesterol intake thus foods that are rich in fat.
S: Spiritual
The patient was encouraged to pray, never lose hope and remain strong to lessen the pain that she experiences despite of her condition.