Case Study CKD

Lyceum of the Philippines UniversityCapitol Site,
Batangas CityTel. 043 723-0706 loc. 166
Lyceum of the Philippines University –

Batangas
College of Nursing
Medical Ward Clinical Duty at

Batangas Medical Center
Case Analysis
of
Chronic Kidney Disease
By:
Advincula, Erryl Justine O.
BSN 4-1 Group A
September 14, 2023

TABLE OF CONTENTS
I. Introduction
II. Patient`s Profile
III. Clinical History
IV. Physical Assessment
V. Anatomy and Physiology
VI. Pathophysiology
VII. Laboratory and Diagnostic Examinations
VIII. Drug Study
IX. Nursing Care Plan (FDAR)
X. Prognosis
XI. Discharge Planning
XII. Conclusion
XIII. Proposed Actions and Recommendations

GENERAL OBJECTIVES
The study was conducted in order to develop the necessary skills needed to
provide quality, efficient, and to the extent of the caliber of excellence in nursing care,
through the application of critical thinking, ability to conceptualize a condition from both
objective and subjective standpoint, and to cater the proliferation of the body of
knowledge that we, student nurses must possess and hone to its sharpest condition.
This study focuses on developing and rendering nursing care toward a 22-year-old
patient diagnosed with Chronic Kidney disease. Connected to this is the analysis of the
condition, how it came to be, its pathophysiology. With all this taken into perspective, all
this compels the student nurses to develop a comprehensive plan of action and
intervention of care in order to provide quality nursing care and ensure optimal health
and well-being.
SPECIFIC OBJECTIVES
● Define Chronic Kidney Disease and its causes, risk factors, signs and symptoms,
the pattern of development, and foreseeable management
● Identify the drugs of choice and their mode of action, specific to the client
● Formulate possible health care plans and intervention of care that extends
outside the hospital
● Provide health teaching and guidance towards care of patient after provision of
institutional care
● Provide an evidenced-based nursing care practice and perform nursing
responsibilities
● Apply theoretical knowledge in performing nursing responsibilities
● Exhibit positive approach and attitude towards the provision of nursing care
I. INTRODUCTION
CKD is a condition in which the kidneys are damaged and cannot filter blood as well as
they should. Because of this, excess fluid and waste from blood remain in the body and may
cause other health problems, such as heart disease and stroke.
II. PATIENT’S PROFILE

Name: Patient JG
Address: Taal, Batangas
Age: 22 years old
Gender: Female
Phone Number: —
Religion: Roman Catholic
Status: Single
Birthdate: June 9, 2001
Place of birth: Taal, batangas
Ethnic Background: Filipino
Educational level: —--
Occupation:
Primary or Secondary Language: Tagalog
Support Person: Sister
Provider of History: Patient and sister

Hospital Number: —--
Diagnosis: Admitting Diagnosis: Chronic Kidney Disease
Physician:
Reason for Admission / Seeking Health Care: For hemodialysis. Patient reported a shortness of
breath, body weakness and dizziness.
III. CLINICAL HISTORY
HISTORY OF PRESENT HEALTH CONCERN

The patient is a 22-year-old female, with chief complaints of shortness of breath,
body weakness and dizziness. The patient is also scheduled for Chronic Kidney
Disease.
PAST HEALTH HISTORY

Past Medical/Surgical History
The patient had no surgical history. The patient claimed that she first
started feeling weak and lightheaded when she was still a teenager.
Family History
The patient stated that their family have a history of diabetes.
Lifestyle and Health Practices

The patient admitted that she puts a lot of sugar in his drinks and she was
used to eating junk foods and processed food. She also stated that she is not
physically active.
IV. PHYSICAL ASSESSMENT
GENERAL SURVEY
The patient is in a sitting position, was awake, responsive, and aware of time and environment
PHYSICAL ASSESSMENT
Date September 13, 2023
Vital Signs BP: 130/90 mmHg
CR: 88 bpm
RR: 20 bpm
T: 36.4°C
O2 Sat: 95%
Body Parts Methods Findings Analysis
HEENT Inspection Lips do not appear Pinkish and smooth lips

dehydrated and patient is not indicate good hydration.
pale in appearance
Neck Inspection Thyroid glands are not Normal

enlarged. There are no
palpable lymph nodes
Chest and Lungs Inspection Symmetrical and normal. No Normal

scar, no precordial bulging
no visible apex beat, and no
prominent dilated vein
Abdomen Inspection Abdomen was not distended. Normal

Incision scar was noted.
V. ANATOMY AND PHYSIOLOGY
Chronic kidney disease is a result of a number

of pathological processes causing irreversible damage
to kidney tissue. There is a mass destruction of
nephrons, so that the kidneys are unable to maintain
fluid and electrolyte balance and excrete waste
products from the body.
A kidney contains over 1 million functioning

units called nephrons. Each nephron is composed of a glomerulus and tubule. The glomerulus
acts to filter the blood free of cells and large proteins, producing an ultrafiltrate composed of the
other smaller circulating elements. The ultrafiltrate enters the tubule, which is highly specialized
at various segments, to produce the final urine by removing substances from the tubular fluid
(reabsorption) or adding substances to the tubular fluid (secretion). Filtration, reabsorption, and
secretion keep the organism in balance in terms of water, minerals, electrolytes, and hydrogen
ion concentration and eliminate the toxic substances produced by the body. The major known
hormonal functions of the kidney influence blood pressure, calcium metabolism, and red blood
cell production.
VI. PATHOPHYSIOLOGY
VII. LABORATORY AND

DIAGNOSTIC EXAMINATIONS
PROCEDURE PERFORMED: BLOOD CHEMISTRY
Blood chemistry tests are one of the most common tests performed to detect and
identify a wide variety of medical conditions, and these are also basic to complex
parameters that help doctors evaluate how well organ systems are functioning during
general physicals and in-depth examinations. A blood chemistry test is a test with a
blood specimen that measures the concentration of certain chemicals in a blood. Blood
chemistry tests provide important information about how well your kidneys, liver and
other organs are working. Abnormal levels of substances in your blood can be a sign of
disease or a side effect of treatment. sick. Blood chemistry tests are used to help
diagnose and monitor many medical conditions before, during, and after treatment.
Test Result Normal Values Significance

BLOOD UREA NITROGEN 42.8 mmol/L 2.1 – 7.1 High. A high BUN level means your
kidneys aren’t working well. But
elevated BUN can also be due to:
Dehydration, resulting from not
drinking enough fluids or for other
reasons
A higher than normal level may be

Creatinine 2043 46-92 due to: Blocked urinary tract.
Kidney problems, such as kidney
damage or failure, infection, or
reduced blood flow.
High levels of uric acid can

sometimes cause gout or kidney
Blood uric acid 791.4 149-369 disease. You may have this test if
you have had or are about to have
certain types of chemotherapy.
Phosphorus 4.2 0.41-1.85 High phosphorus, also called

hyperphosphatemia, means you
have extra phosphorus in your
blood. High phosphorus is often a
sign of kidney damage.
VIII. Drug Study

IX. NURSING CARE PLAN (FDAR)

NURSE’S NOTES
Date/Shift Time Nurse’s Notes

Feb 20, 2023 3pm to 11pm F: Elevated Blood pressure
D:
VS: HR - 88, BP - 140/90, RR - 19, Temp - 36.2, O2Sat - 98%
Patient Verbalized “Ako po ay nakayuko dahil nasakit po ang aking ulo”
A: Vital signs taken and recorded
Measured intake and output

Provided calrm and restful surroundings
Educated patient a stress management and relaxation technique.
R: Latest BP: 140/90
Date/Shift Time Nurse’s Notes

Feb 21, 2023 3pm to 11pm F: For hemodialysis
D: > V/S: BP - 140/100, RR - 19, PR - 75
With IJ catheter intact
With heplock intact
A: > V/S taken and recorded

Placed patient in a comfortable position
Bedside care done
Provided calm and restful surroundings
NPI done
R: Sent to hemodialysis
Feb 22, 2023 3-11pm F: Altered sleeping pattern

D:V/S as follows: BP-130/90 RR-20 PR-88 o2sar-96 Tem-36.4
Patient verbalized “hindi ako makatulog ng ayos lalo na sa gabi”.
A: Monitored vital sign
Placed patient in a comfortable position
Provided calm and restful surroundings
Advised
patient not to
take a
naps
during day
time
I and O taken and recorded
R: The patient was able to verbalize control of pain as evidenced by
decreased in pain scale from 4 to 1 out of 10
X. PROGNOSIS
The prognosis of chronic kidney disease depends on a number of factors, and for
some people, it can progress to kidney failure. For some though, it never causes any
problems. One of the major factors relating to the overall prognosis will relate to the
underlying cause of the patient’s chronic kidney disease. The life expectancy for a
person receiving dialysis is around 5–10 years, though many live for 20–30 years.
People who receive a donor kidney from a living donor tend to go 15–20 years before
needing a new kidney. Donor kidneys from deceased donors tend to last 10–15 years
before needing to be replaced..
XI. DISCHARGE PLANNING

Medications:
● Continue oral medications as prescribed.
Environment:
● Advised patient and partner to have a clean and sleep-conducive environment,
comfortable room temperature, and appropriate ventilation and lighting.
● Inform the significant other to pay attention to the patient's safety at home in
order to speed up recovery, minimize potential infection sources, and ensure that
family members are aware of the patient's need for assistance.
● Encourage the patient to do light stretching exercises and walk daily to relieve
tension in the body.
● Advised patient to take a break from exhausting work and promote a relaxing
environment.
Treatment:
● Advise the patient to have an adequate rest for faster recovery.
● Instructed the patient to increase her oral fluid intake.
● Informed patient to avoid lifting heavy object
Hygiene:
● Instructed the patient to wash his hands before and after eating.
● Reiterated the importance of hand washing to avoid infection
Outpatient:
● Instructed patient and significant other to do a follow-up check-up or contact the
physician if recurrences and other issues occur.
Diet:
● Instructed significant other to give
support to the patient by giving her the best option of healthy foods that will make
her motivated to eat and enjoy them at the same time.
● Advised patient to avoid salty and sodium rich foods as it causes the body to
retain fluids.m
● Suggested to patient to reduce or limit alcohol intake.
Spiritual:
● Advised patient to continue spiritual practices, so long as it does not put the
patient’s health into compromise.
XII. CONCLUSION
If left untreated, CKD can progress to kidney failure and early cardiovascular
disease. When the kidneys stop working, dialysis or kidney transplant is needed for
survival. Kidney failure treated with dialysis or kidney transplant is called end-stage
renal disease (ESRD).
XIII. PROPOSED ACTIONS AND RECOMMENDATIONS

The most important step you can take to treat kidney disease is to control your
blood pressure. High blood pressure can damage your kidneys. You can protect your
kidneys by keeping your blood pressure at or less than the goal set by your health care
provider. For most people, the blood pressure goal is less than 140/90 mm Hg.
Work with your health care provider to develop a plan to meet your blood
pressure goals. Steps you can take to meet your blood pressure goals may include
eating heart-healthy and low-sodium meals, quitting smoking, being active, getting
enough sleep, and taking your medicines as prescribed.

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Lyceum of the Philippines UniversityCapitol Site,

Batangas CityTel. 043 723-0706 loc. 166

Lyceum of the Philippines University –

Medical Ward Clinical Duty at

Chronic Kidney Disease

September 14, 2023

II. Patient`s Profile

III. Clinical History

IV. Physical Assessment

V. Anatomy and Physiology

VII. Laboratory and Diagnostic Examinations

VIII. Drug Study

IX. Nursing Care Plan (FDAR)

XI. Discharge Planning

XIII. Proposed Actions and Recommendations

II. PATIENT’S PROFILE

Provider of History: Patient and sister

III. CLINICAL HISTORY

HISTORY OF PRESENT HEALTH CONCERN

PAST HEALTH HISTORY

Lifestyle and Health Practices

IV. PHYSICAL ASSESSMENT

Date September 13, 2023

Vital Signs BP: 130/90 mmHg

Body Parts Methods Findings Analysis

HEENT Inspection Lips do not appear Pinkish and smooth lips

Neck Inspection Thyroid glands are not Normal

Chest and Lungs Inspection Symmetrical and normal. No Normal

Abdomen Inspection Abdomen was not distended. Normal

V. ANATOMY AND PHYSIOLOGY

Chronic kidney disease is a result of a number

A kidney contains over 1 million functioning

VII. LABORATORY AND

Test Result Normal Values Significance

A higher than normal level may be

High levels of uric acid can

Phosphorus 4.2 0.41-1.85 High phosphorus, also called

sign of kidney damage.

VIII. Drug Study

IX. NURSING CARE PLAN (FDAR)

Date/Shift Time Nurse’s Notes

A: Vital signs taken and recorded

Measured intake and output

Educated patient a stress management and relaxation technique.

R: Latest BP: 140/90

Advincula, Erryl Justine O.

Date/Shift Time Nurse’s Notes

With heplock intact

A: > V/S taken and recorded

Bedside care done

Provided calm and restful surroundings

Advincula, Erryl Justine O.

Feb 22, 2023 3-11pm F: Altered sleeping pattern

XI. DISCHARGE PLANNING

XIII. PROPOSED ACTIONS AND RECOMMENDATIONS

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