Reporter 1: Christine Pahunang (Intro, Present hx, and NCP 1-3)

Reporter 2: Patricia Quiblat (Past hx and NCP 4-6)

Reporter 3: Sheila Yongco (Patho and DS)

GRP 3 GENWARD SCRIPT

REPORTER 1: Good morning blockmates and to our esteemed clinical instructors, we are group 3 and we are
here to present a case from our general ward rotation which is the case of A 53-YEAR-OLD ADULT FEMALE
PATIENT DIAGNOSED WITH UREMIA SECONDARY TO CHRONIC KIDNEY DISEASE SECONDARY TO
HYPERTENSIVE KIDNEY DISEASE, DIABETIC KIDNEY DISEASE AND URATE NEPHROPATHY, AND
HYPERTENSIVE CARDIOVASCULAR DISEASE

REPORTER 1: The first case is about patient MTQ, a known case of Chronic Kidney Disease stage V who
came in with a chief complaint of increasing creatinine levels. Two months prior to admission, the patient was
noted to have palmar pallor without any associated signs and symptoms. Patient MTQ went for consultation at
a private medical doctor, and work-up done through complete blood count (CBC) revealed low hemoglobin
level of 8.2 g/dl. and increased creatinine level of 8.45 mg/dL. The patient was managed as a care of anemia
secondary to Chronic Kidney Disease and she was started with medications including Epoetin, Ferrous sulfate,
Furosemide, Ketoanalogue, Sodium bicarbonate, and Febuxostat with good compliance to medications and no
symptom progression. One week prior to admission, during follow up, work up was done revealing increased
creatinine level to 12.05 mg/dL. Patient was then advised initiation of hemodialysis, which prompted
subsequent admission on February 10, 2023.

REPORTER 2: For the patient’s past medical history, Since 2016, Patient MTQ has been recognized as having
Chronic Kidney Disease. She is known to be hypertensive, with a typical blood pressure reading of 130/80 and
a maximum reading of 150/100. In 2016, the patient had a Cerebrovascular Disease infarct with a Modified
Rankin Scale (MRS) score of 0. Since 2016, the patient has been diagnosed with type 2 Diabetes Mellitus. She
is compliant with her maintenance medications.

REPORTER 3: Chronic kidney disease is the progressive loss of renal function and it has consequences
manifested throughout all organ systems. The following are the factors that predisposed the patient to an
increased risk for CKD: First, upon assessment, patient MTG reported that she had a history of hypertension
and diabetes mellitus. Elevated blood pressures cause glomerular and vascular changes that may eventually
result in gradual decline in renal function. The patient also has a family history of DM and leukemia.

REPORTER 3: First we will be following through with the diagnosis of Diabetic Kidney Disease (DKD). The
patient was diagnosed with type 2 diabetes mellitus in 2016 predisposing her to the development of the
condition. Because of the patient’s hyperglycemia, as evidenced by her latest CBG of 186 mg/dL, this would
trigger the activation of various pathways and the production of oxygen reactive species (protein kinase C,
polyol, hexosamine, and advanced glycation end products) causing vascular inflammation and fibrosis.
Because of systemic and intraglomerular hypertension, there is resulting damage to the podocytes leading to
an impaired GFR, albuminuria and proteinuria, as evidenced by a presence of protein in the patient’s
urinalysis. Subsequently, the formation of epithelial cells into fibroblasts led to chronic tubular injury and an
increase in urea and creatinine, which indicates the patient’s need to undergo hemodialysis and the medication
NaHCO3 650 mg tab 1 tab TID PO.

REPORTER 3: Patient MTQ also had long-standing hypertension. Due to constant high pressures in the renal
circulation, this would cause progressive loss of autoregulatory properties gradually leading to increased
intraglomerular pressure as well as systolic blood pressure. For this, the patient was given Furosemide 40 mg
1 tab BID PO. As a consequence of the direct transmission of hypertension from larger vessels to the
glomerular structures, pulsation, stretching, and endothelial injury occurs ultimately leading to a diagnosis of
Hypertensive Kidney Disease (HKD). An adaptive reaction to the loss of renal microcirculation is arterial wall
hypertrophy, lumen narrowing, and flow reduction manifested by a non-pitting edema on the right hand. This
was managed with Cilostazol 100 mg tab 1 tab BID PO.

REPORTER 3: Patient MTQ’s diagnosis of Urate Nephropathy is traced back to her impaired GFR. Tubular
injury to the kidney caused by the build-up of uric acid crystals reduces the excretion of electrolytes and uric
acid, which would elevate uric acid levels. The body's response under these circumstances stimulates
macrophage activation, leading to inflammation and apoptosis and eventually fibrosis or scarring of the
kidneys. As such, the patient was given Febuxostat 40 mg tab 1 tab OD PO in order to manage hyperuricemia.

REPORTER 3: The hyperfiltration and hypertrophy of residual nephrons represent a major cause of
progressive renal dysfunction, the increased glomerular capillary pressure may damage the capillaries which
would result to secondary focal and segmental glomerulosclerosis and eventual global glomerulosclerosis, thus
the diagnosis of Chronic Kidney Disease (CKD).

REPORTER 3: Anemia related to renal dysfunction is often of normocytic, normochromic, and

hyperproliferative features due to the decreased erythropoietin production. This is evidenced by a decreased
Hgb level of 9.5 g/dL, decreased Hct level of 29.9%, decreased MCV count and MCH. This was clinically
manifested by palmar pallor. Patient MTQ was then given EPO 6000 IU SQ 2x/week to manage anemia. She
was also prescribed Ferrous Sulfate 1 tab TID PO to prevent and treat iron deficiency anemia.

REPORTER 3: Decreased active vitamin D production leads to hypocalcemia, which in turn decreases the GI
absorption of calcium and phosphorus as well as the suppression of parathyroid hormone excretion.
Hyperphosphatemia may also occur in renal failure due to the impaired excretion of phosphorus. Together, this
would cause the parathyroid gland to hypertrophy increasing parathyroid hormone secretion. As a result,
calcium metabolism alterations occur that can lead to osteodystrophy and metastatic calcification.
REPORTER 3: Finally, as Chronic Kidney Disease (CKD) progresses, there would be an accumulation of
uremic toxins in the bloodstream, which would factor the final diagnosis of Uremia. Ketoanalogue 2 tabs TID
PO was given to prevent unnecessary increases in urea levels in patients with CKD. Uremia had also indicated
the insertion of a permanent catheter on February 11, 2023 and the prescription of Tramadol + PCM 375/325
mg, 1 tab RTC q8 PO to manage pain.

REPORTER 3: Lastly, the patient’s hypertension and diabetes have also contributed to the development of
Hypertensive Cardiovascular Disease (HCVD). Consistent high blood pressure increases the workload on the
heart resulting in the structural and functional changes of the myocardium and injury to the endothelium. This
causes the activation of immune response at the site of inflammation and the accumulation of lipid-laden
macrophage and extracellular matrix. Resultantly, atherosclerotic plaque develops. As such, the patient was
given Atorvastatin 20 mg tab 1 tab OD HS and ISMN 30 mg tab 1 tab OD HS PO as a prophylaxis of
cardiovascular events and HCVD, respectively.

REPORTER 3: Furthermore, hypertension produces a greater force for the heart to work in pumping blood
because of the increased resistance in the arteries. Overtime, the increased workload can cause the muscle
wall of the left ventricle to thicken and become stiff, which is manifested by the patient as evidenced by
cardiomegaly multi chambered form as seen in her chest AP.

REPORTER 3: So overall, the pathophysiology of uremia in the context of CKD secondary to hypertensive
kidney disease, diabetic kidney disease, and urate nephropathy is complex and involves multiple
interconnected mechanisms that ultimately lead to impaired kidney function and the accumulation of toxic
waste products in the body.

REPORTER 1: Moving on to the formulated nursing care plans. Our group was able to formulate 6 nursing
diagnoses. First is the nursing diagnosis of Decreased cardiac output RT accumulation of toxins and
impaired contractility secondary to pericardial effusion AEB elevated creatinine levels, elevated BUN
levels, elevated blood uric acid, and non-pitting edema R hand. Objectives cues for this include creatinine
level of 12.05 mg/dl, BUN of 62.5 mg/dl, blood uric acid of 14.36 mg/dl, sodium serum level of 145.15,
non-pitting edema R hand, cardiovascular lab result of small to moderate-sized pericardial effusion with largest
pocket posterior to the right atrium (1.2cm), and elevated blood pressure with highest systolic BP of 140 and
highest diastolic BP of 90. Nursing interventions for this include the following:
1. Monitoring the weight closely since decreased cardiac output could result in retention of fluid which can
worsen the symptoms the patient is experiencing
2. Monitor intake and output closely as this will allow the nurse to maintain appropriate fluid balance.
3. Maintaining activity restrictions such as bed rest to lessen physical stress and tension that affect blood
pressure
 4. Administering antihypertensive drugs to decrease myocardial workload
5. Preparing the patient for dialysis to reduce uremic toxins and correction of electrolyte imbalances

REPORTER 1: The second nursing diagnosis is Excess fluid volume RT fluid retention secondary to CKD
stage 5 AEB elevated creatinine levels, elevated blood uric acid, low hemoglobin and hematocrit count,
and non-pitting edema. No subjective cues were noted. As for the objective cues, it includes the diagnosis of
CKD stage 5, latest (02/13) creatinine level of 10.12 mg/dl, blood uric acid of 14.36 mg/dl, latest (02/13)
hemoglobin count of 11.4 g/dl, hematocrit count of 34.5 %, and non-pitting edema on right hand. Nursing
interventions would include:
1. Monitoring intake and output, to detect changes in renal function and adjusting treatment accordingly
2. Monitoring the patient’s weight, to best monitor for fluid status
3. Maintaining fluid and sodium restrictions as indicated, To reduce fluid volume overload
4. Administering furosemide (indicated for edema) and FeSO4 (treatment for iron-deficiency anemia),
5. Preparing the patient for dialysis to reduce fluid volume excess and correct electrolyte and acid-base
imbalances

REPORTER 1: The third nursing diagnosis is Electrolyte Imbalance related to altered serum levels and
renal function secondary to CKD stage 5 AEB elevated Sodium serum level of 145.15 mg/dl (2/11/23)
and elevated Phosphorus serum level of 5 mg/dl (2/11/23). No subjective cues were noted. Objective cues
includes the following, diagnosis of uremia sec to CKD, latest (02/02/2023) creatinine level of 12.05 mg/dl,
(02/11/2023) 12.58 mg/dl, and (02/13/2023) 10.12 mg/dl, latest (2/11/23) Sodium serum level of 145.15 mg/dl.
Nursing interventions would include:
1. Maintaining and monitoring serum electrolyte balance, to ensure that other electrolytes do not become
imbalanced
2. Regularly checking the patient’s level of consciousness and muscular movement, strength, and tone as
hypernatremia may cause nerve and muscular irritability and changes in mentation.
3. Administering electrolyte replacement, intravenous calcium gluconate, and intravenous fluids as
prescribed
4. Educate the patient about dietary sources of sodium and the use of salt substitutes.some studies show
of benefits to the heart when using potassium-based salt substitutes.

REPORTER 2: Fourth nursing diagnosis is Acute pain RT intrajugular permanent catheter insertion AEB
reports of 3 out of 10 pain on a scale of 1-10 characterized as unremitting pain despite ATC pain
medication. Subjective cues include verbalization of the patient about pain “medyo sakit pa ni”, “tungod sa
sakit dili maka change sa position”. Objective cues for this include reports 3/10 pain on a scale of 1-10.
Nursing interventions for this diagnosis include:
1. Use of relaxation technique, as this help produce a sense of tranquility for the patient
2. Administering analgesics as ordered by the physician.
REPORTER 2: For the fifth nursing diagnosis, Readiness for enhanced health management RT presence
of permanent intrajugular catheter. No subjective cues were noted. As for the objective cues, there is a
written discharge order from the attending physician. Nursing interventions would include:
1. Verifying the client's understanding on the importance of therapeutic regimen to provide opportunity to
assure accuracy and completeness of knowledge based for future learning.
2. Accept the patient’s evaluation of their own strengths/limitations while working together to improve
abilities in order to promote a sense of self-esteem and confidence to continue efforts.

REPORTER 2: The last nursing diagnosis is, Risk for infection RT immunosuppressive effects of CKD
and/or diabetes and uremia. There were no subjective cues noted however, for the objective cues, the
patient has a blood uric acid level of 14.36 mg/dl and a decreased Lymphocyte count of 13% recorded at
02/02/23. Nursing interventions would include:
1. Monitoring the patient's vital signs and temperature regularly
2. Ensuring strict aseptic technique during procedures
3. Health education regarding maintaining intact skin and mucous membranes.

(IF APILON)
REPORTER 3: When it comes to the prognosis of the patient, it was concluded that the patient falls under an
excellent prognosis, having a percentage of 85%. With the patient’s diagnosis of Chronic kidney disease (CKD)
stage 5, at this stage, the kidneys are functioning at less than 10-15% of normal capacity. So the patient
received therapy to control creatinine levels and chose continuous hemodialysis. The patient also had mobility
limitations due to post-operation, but was able to perform ADLs. Patient and SO were compliant with treatment
and dialysis appointments, and adhered to medication and supplement intake. Patient handled physical
limitations and emotional impact well. Lastly, there were no issues with social interaction during hospital stay
and discharge.