Case Study

On
Chronic Kidney Disease
probably to 2°
Hypertension

Submitted by:
Lukban, Cheryl A.
A3BB
 Introduction
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.

Chronic kidney disease is identified by a blood test for creatinine. Higher

levels of creatinine indicate a falling glomerular filtration rate (rate at which the
kidneys filter blood) 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 (testing of a urine sample) 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 (removing a small sample of kidney
tissue) are employed to find out if there is a reversible cause for the kidney
malfunction.[1] Recent professional guidelines classify the severity of chronic
kidney disease in five stages, with stage 1 being the mildest and usually causing
few symptoms and stage 5 being a severe illness with poor life expectancy if
untreated. Stage 5 CKD is also called established chronic kidney disease and is
synonymous with the now outdated terms end-stage renal disease (ESRD),
chronic kidney failure (CKF) or chronic renal failure (CRF).

There is no specific treatment unequivocally shown to slow the worsening

of chronic kidney disease. If there is an underlying cause to CKD, such as
vasculitis, this may be treated directly with treatments aimed to slow the damage.
In more advanced stages, treatments may be required for anemia and bone
disease. Severe CKD requires one of the forms of renal replacement therapy; this
may be a form of dialysis, but ideally constitutes a kidney transplant.
 Objectives

General Objective:

The purpose of this study is to provide deeper theoretical and

practical knowledge and information about chronic kidney disease.

Specific Objective:

1. To provide information on the related causes of chronic kidney diseases

2. To provide information regarding postpartum care for patients who had

the similar illness of chronic kidney disease

3. To provide a framework of study regarding the subject that can serve as

the foundation of future studies and research
 Patient Data Profile
Demographic Data
Name: Mrs. X
Age: 75 y/o
Sex: Female
Civil Status: Married
Religion: Roman Catholic
Birth Place: Manila
Birth Date : September 13, 1933

Admission Data
Date and Time of Admission: August 8, 2009 at 10: 45pm
Attending Physician: Dr. Solima
Admission Diagnosis: Chronic Kidney Disease probably 2° to hypertension

Medical History
2007 – breast removal

Family Medical History

Father’s Side: None
Mother’s Side: None

Social History
Patient’s Occupation: Housewife/tinder
Partner’s Occupation: Carpenter
*partner is deceased
 Gordon’s Functional Assessment
Pattern Before During Analysis and
Hospitalization Hospitalization Interpretation
Self Perception- Patient felt she is Patient feels weakNormal concern
Self Concept still strong and wants to be regarding on her
Pattern out of the hospital
body strength
Role Relationship Patient primary Patient primary Patient is
Pattern support are her support are still dependent on her
children her children children
Sexuality and Patient believed Patient still Normal reaction
Reproductive she is too old believed she is too
on sex and
Health old reproductive
health because of
her age
Cognitive There are no There are no Normal cognitive
Perceptual Pattern problem in hearing problem in hearing patterns
and visual acuity and visual acuity
Coping Stress Psychosocial: Psychosocial: Patients display
Tolerance Pattern Ego Integrity Ego Integrity normal
Vs Vs psychosocial,
Despair Despair psychosexual and
Psychosexual: Psychosexual: cognitive
Genital Genital development.
Cognitive: Cognitive: Emotional stability
Formal Formal
Operational She still talks to
She talks to her her children and
children and friends
friends
Value Belief She hear mass Patient seek God’s Patient has strong
Pattern regularly and pray guidance for well religious belief.
the rosary being
Elimination Patient use to void Patient is place in Patient voiding
4 times a day and folly catheter and pattern are altered
regularly defecates defecation of stool due to the folly
at least once a day is altered catheter inserted
Activity Exercise Patient prefer to Patient cannot Patient activity is
Pattern walk for exercise stand nor move altered because of
here extremities being bedridden
and sits on bed
Sleep Rest Pattern The patient has an The patient now Interrupted sleep
average of 6 hours has irregular during
of continuous pattern of sleep hospitalization
sleep because of
environmental
factors and
hospital procedure
Safe Environment No allergies No allergies Normal
Oxygenation
Nutrition Patient able to eat Patient fluid is Iv fluids are given
and finish one full partially supplied for hydration. Diet
course meal and intravenously by of the patient is
able to eat any PNSS 1L x restricted.
kinds of fruits, 10gtts/min. her
meat and diet is maintain
vegetables. Low salt low fat
Maximum intake and Na intake is
of fluids is 3-5 limited. She eats
glass a day. 3x a day but in
small amount. The
maximum intake
of fluid is 2-3 glass
a day.
 Anatomy and Physiology

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 (see below) 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.
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 pH (i.e., level of acidity or alkalinity) of the blood and
the general balance of ions in the blood, and hence in the body fluid as a
whole.
 Conserving essential substances such as glucose and amino acids.
Parts and Function:
Renal Vein - This has a large diameter and a thin wall. It carries blood away
from the kidney and back to the right hand side of the heart. Blood in the kidney
has had all its urea removed. Urea is produced by your liver to get rid of excess
amino-acids.
Blood in the renal vein also has exactly the right amount of
water and salts. This is because the kidney gets rid of excess water and salts. The
kidney is controlled by the brain. A hormone in our blood called Anti-Diuretic
Hormone (ADH for short) is used to control exactly how much water is excreted.
Renal Artery - This blood vessel supplies blood to the kidney from the left
hand side of the heart. This blood must contain glucose and oxygen because the
kidney has to work hard producing urine. Blood in the renal artery must have
sufficient pressure or the kidney will not be able to filter the blood.
Blood supplied to the kidney contains a toxic product called
urea which must be removed from the blood. It may have too much salt and too
much water. The kidney removes these excess materials; that is its function.
Pelvis - This is the region of the kidney where urine collects.
Ureter - the ureter carries the urine down to the bladder.
Medulla - The medulla is the inside part of the kidney. This is where the
amount of salt and water in your urine is controlled. It consists of billions of loops
of Henlé. These work very hard pumping sodium ions. ADH makes the loops work
harder to pump more sodium ions. The result of this is that very concentrated
urine is produced.
Cortex - The cortex is the outer part of the kidney. This is where blood
is filtered. We call this process "ultra-filtration" or "high pressure filtration"
because it only works if the blood entering the kidney in the renal artery is at high
pressure.
 Billions of glomeruli are found in the cortex. A glomerulus is a tiny
ball of capillaries. Each glomerulus is surrounded by a "Bowman's Capsule".
Glomeruli leak. Things like red blood cells, white blood cells, platelets and
fibrinogen stay in the blood vessels. Most of the plasma leaks out into the
Bowman's capsules. This is about 160 litres of liquid every 24 hours.
Most of this liquid, which we call "ultra-filtrate" is re-absorbed in the
medulla and put back into the blood.
Glomerulus and Bowman's Capsule - This is where ultra-filtration takes
place. Blood from the renal artery is forced into the glomerulus under high
pressure. Most of the liquid is forced out of the glomerulus into the Bowman's
capsule which surrounds it. This does not work properly in people who have very
low blood pressure.
Proximal Convoluted Tubules - Don't worry about remembering the name
for your GCSE biology. Jolly good though if you can. Proximal means "near to" and
convoluted means "coiled up" so this is the coiled up tube near to the Bowman's
capsule.
This is the place where all that useful glucose is re-absorbed from the
ultra-filtrate and put back into the blood. If the glucose was not absorbed it would
end up in your urine. This happens in people who are suffering from diabetes.
Loop of Henlé - This part of the nephron is where water is reabsorbed.
Kidney cells in this region spend all their time pumping sodium ions. This makes
the medulla very salty; you could say that this is a region of very low water
concentration. If you remember the definition of osmosis, you will realise that
water will pass from a region of high water concentration (the ultra-filtrate and
urine) into a region of low water concentration (the medulla) through cell
membranes which are semi-permeable.
Distal Convoluted Tubules - Distal means "distant" so it is at the other
end of the nephron from the Bowman's capsule. This is where most of the salts in
the ultra-filtrate are re-absorbed.
Collecting Duct - Collecting ducts run through the medulla and are
surrounded by loops of Henlé. The liquid in the collecting ducts (ultra-filtrate) is
turned into urine as water and salts are removed from it. Although our kidneys
make about 160 litres of urine every 24 hours, we only produce about ½ litre of
urine.
It is called a collecting duct because it collects the liquid produced by
lots of nephrons.
 Pathophysiology

Secondary Hypertension

Arteriosclerotic lesions of the afferent and efferent arterioles

Falling glomerular filtration rate

Decrease capability of the kidneys to excrete waste products

Due to hypertension, there are lesion to the afferent and efferent arterioles
decreasing the effectiveness of the filtration of blood in the glomerular that leads
to the decrease capability of the kidney to properly excrete waste products
 Diagnostic Procedures
Urinalysis
August 21, 2009
Macroscopic Microscopic
Color Light yellow RBC 12-15 / HPF
Transparency Cloudy WBC Many / HPF
Specific Gravity 1.015 Epithelial Cells Moderate
Reaction 6.0 Mucus Threads Few
Chemical Tests Bacterial Many
Sugar Negative Crystals
Albumin Trace A. Urates Many
Special Tests A. Phosphate
Foam’s test Calcium Coxalate
Ketone Others
Pregnancy test
Analysis and Interpretation:
Laboratory results revealed that there is presence of albumin in the blood and no
sugar present.

Urinalysis
August 19, 2009
Macroscopic Microscopic
Color Light yellow RBC 2-3 / HPF
Transparency Slightly cloudy WBC 2-3 / HPF
Specific Gravity 1.020 Epithelial Cells Few
Reaction 5.0 Mucus Threads Occasional
Chemical Tests Bacterial Few
Sugar +2 Crystals
Albumin +3 B. Urates Moderate
Special Tests B. Phosphate
Foam’s test Cast Coarse granular 3-5 /
LPF
Ketone Others Waxy cast 2-4 / PLF
Analysis and Interpretation:
Laboratory results revealed that there is presence of albumin and sugarin the
urine.
Hematology Received : August 18, 2009
Result Normal Analysis
WBC 10.4 4.0-11.0x10^9 Normal
/L
RBC 2.36 4.0-6.0x10^12 Result was below normal. This
/L indicates alteration in erythropoietin
production secondary to renal
malfunction.
HGB 70 120-180 g/L Result was below normal. This
shows the decrease in the oxygen
carrying capacity of the blood
secondary low hematocrit.
HCT 0.224 0.370-0.540 Result was below normal, thus
showing anemia related to
insufficient RBC production.
MCV 94.8 20-100fL Normal
MCH 29.6 27-31pg Normal
MCHC 312 320-360 g/L Result was below normal
RDW 15.2 11.5-15.0% Normal
Differential count
Bands 01 2-6% Result was below normal
Segmented 93 50-70% Result was above normal
Lymphocytes 05 20-44% Result is above the normal range,
indicating bacterial infection.
Monocytes 01 2-9% Result was below normal

August 18,2009
Test Result Unit Normal Results Unit Normal Analysis and
values conv. values Interpretation

Creatinine 674 umol 53.00 1.30 11.50 mg/ 0.60 1.30 Result was above
high /L dl normal thus
showing inability
of the kidney to
excrete
nitrogenous
 waste.

Sodium 133 mmol 136 148 122.00 mE 136 148Result was below
low /L q/dl normal thus
showing the fluid
and electrolyte
imbalance.
Potassium 2.5 mmol 3.65 5.20 6.30 mE 3.60 5.20 Result was below
low /L q/dl normal thus
showing the fluid
and electrolyte
imbalance.

August 28, 2009

Test Result Unit Normal Result Unit Normal Analysis and
values conv. values Interpretation
Creatinine 674 umol 53.00 1.30 7.62 mg/ 0.60 1.30Result was above
high /L dl normal thus
showing inability
of the kidney to
excrete
nitrogenous
waste.
Sodium 133 mmo 136 148 133.00 mE 136 148 Result was below
low l/L q/dl normal thus
showing the fluid
and electrolyte
imbalance.
Potassium 2.5 mmo 3.65 5.20 2.50 mE 3.60 5.20 Result was below
low l/L q/dl normal thus
showing the fluid
and electrolyte
imbalance.
 Discharge Planning

M- Medication
 Instructed to complied strictly with the following home medications
 Vitamin B Complex I tab OD PO
 CaCO I tab TID PO
 NaHCO3 I tab TID PO
 JNH-RIF-PZO-IHN I tab OD PO

E- Exercise
 Encourage mild exercise

T- Treatment
 Advice patient to avoid stress related factors

H – Health teachings
 Encourage deep breathing exercise
 Adequate bed rest

O- Out patient
 Informed client to follow up check up
 Emphasize the need to be present in medical procedures schedule

D- Diet
 Maintain on low salt low fat diet
 Limit fluid intake
 Evaluation
This case study attempted to provide complete information about the illness
regarding the patient. There were theoretical and practical limitations to the
study and one important defiecncy was the author’s relative inexperience in
developing a complete case study. Nevertheless, the information included in this
paper was thoroughly studied and researched and in accordance with the
prescribed requirements.

This study has completely met the objective in providing information about
chronic kidney disease and postpartum care. It also provide framework of study
regarding the topic discuss.