1

 INTRODUCTION (SELF):-
As per my clinical posting I was posted in the Neuro ICU ward in AGMC & GBP Hospital.
During my clinical posting I was found a patient who was suffering from headache,
confusion, slurred speech. During his admission time he was suffering loss of conciousness
and doctor diagnosed him as Subdural haemorrhage. I had taken this diagnosis for my case
study

 IDENTIFICATION DATA OF PATIENT:-

Name of the patient: Mr. Nitesh Ch. Paul.

H/o: Mrs. Bina Deb.

Age: 62 yrs

Gender: Male

Religion:Hindu

Educational Status:VI passed

Occupation: He was a farmer but because of his age now he is not doing any thing.

Income: 25,000 rupees/month

Marital status: Married

Address: Amtali

Ward: Dialysis Ward

I.P. No:78333

A.R. No: 555

Date of Admission: 27/09/2023

Diagnosis: Chronic kidney disease

Informants: Patient himself and family members

Date of care started: 29/09/2023

Date of care ended: 01/10/2023

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 CHIEF COMPLAINTS WITH DURATION:-

He was suffering fluid nausea,vomiting,weakness. He was admitted to the hospital with the
chief complaints of decreased urine output, edema in legs,hands,abdomen since 1month.

 HISTORY OF PRESENT ILLNESS:-

Present Medical History:
He is suffering from decreased urine output, nausea,vomiting,edema in hands,legs,abdomen,
since 1month. Patient already have diabetes malitus and hypertention since 2years. After
seeing his condition his family members take him to the GBP hospital.

Present Surgical History:

Patient have no any surgical history in present.

 HISTORY OF PAST ILLNESS:-

Past Medical History:
In his past medical history patient was suffering fever, cough, diabetes, hypertension.

Past Surgical History:

Patient is not having any past surgical history.

 FAMILY HISTORY:-
Types of Family: Nuclear

No. of family members: 5(five)

History of Illness: In his family there have the history of diabetes malitus.

Relationship among the family members: Good

Family Chart:-
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Name of the Age Relation

Sl. family Gender with Education Occupation Marital Health
No. members patient status Status
1. Mr.Nitesh ch. 62yrs. Patient VII Passed _ Married Unhealthy
paul Male (self)

2. Mrs.Bina Deb. 58yrs. Wife IV passed Housewife Married Healthy

Female

3. Mr.Kanti Paul. 35yrs. Son MA Passed Teacher Married Healthy

Male

4. Mrs.Anamika 28 yrs. Daughter- BA Passed Housewife Married Healthy

Paul. Female in-low
5. Miss.Piyali Paul. 7yrs Grand Class II Student Unmarried Healthy
Female daughter standard

Family Tree: INDEX

------- Male

------ Female

----- Female Patient

Mr.Nitesh ch Paul Mrs.Bina Deb

------ Dead Female

------ Dead Male

Mr.Kanti Paul Mrs.Anamika paul

Miss.Piyali Paul

 PERSONAL HISTORY:-
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Nutritional Status:Dull.

Habits: He has no any bad habit.

Hygiene: Not maintained properly.

Allergens: He has no any problem of allergy.

Sleeping Pattern: His sleeping duration is 5-6 hours.

Bowel and Bladder Pattern: His bowel and bladder pattern are irregular.

Activities of Daily Living: Dull due to illness.

 SOCIO-ECONOMIC HISTORY:-
Head of the family: Mr.Kanti Paul

Income: 25,000 rupees/month

House Type: Pakka.

Location:Urban.

Water supply: Tap water and tubewell

Electricity: Available

Ventilation: Well ventilated

Sanitation: Good.
Drainage System: Good.

 PHYSICAL EXAMINATION:-
Height: 146cm.

Weight: kg.
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VITAL SIGNS:
Vital Signs Patient’s Value Normal value Remarks

Temperature 98.40F 98.6 F Normal

Pulse 86 beats/min. 60-100 beats/min Normal
Respiration 22 breaths/min. 16-24 breaths/min Normal
Blood Pressure 160/100 mm-hg 120/80 mm-Hg. Increased

GENERAL APPEARANCE:-
Body Built: Moderate.

Health: Unhealthy

Activity: Dull.

Consciousness: Conscious

Posture and Gait: Normal

HEAD AND TOE EXAMINATION:-

HEAD:

Scalp: Scalp is Clear

Dandruff: There have no dandruff in his head

HAIR:

Colour: Hair color is black

Texture: Hair texture thin

Distribution: Hair are normally distributed

FACE:

EYES:

Eyebrows: His eyebrows are symmetrical.

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Eyeballs:His eyeballs are normal.

Eyelids: His eyelids are normal and no inflammation.

Eyelashes: His eyelashes are normal
Conjunctiva: Conjunctiva are normal but light pale in color
Sclera: Sclera is normal and white in color
Cornea: Cornea is normal and corneal ulcer absent
Pupillary Reaction: Reacted to light
Vision: Uses spectacle since 10 years.
EARS:
External Pinna: Normal
Discharge: No discharge
Hearing acuity: Normal.
NOSE:
Nostrils: Nasal flaring absent
Nasal Septum: No deviation is there
Discharge: Absent.
Sense of Smell: Normal.
MOUTH:
Lips: Dry
Odour of the mouth: Good.
Mucus Membranes and Gums: Normal
Teeth: Dental carries present.
Throat and Pharynx: Normal
NECK:

Lymph Nodes: No enlargement

Thyroid Gland: Normal and no enlargement

Range of Motion: He is unable to do range of motion.

CHEST:

Symmetry: Chest are Symmetrical

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Breath Sound: Wheezing sound absent

Heart Sound: Normal S1 and S2 heard.

Breast: Normal

ABDOMEN:

Inspection: Abdominal enlargement is preset due to illness.

Auscultation: Bowel sound is not present.

Palpation: No organomagally

Percussion: Fluid accumulation is present.

EXTREMITIES:

Upper extremities: Edema present in upper extremities but syndectyle and polydectyle
absent.

Lower extremities: Edema present in lower extrimities and syndectyle and polydectyle
absent.

Range of Motion: He is unable to do rangr of motion.

BACK: Spine continuity normal and decubitus ulcer absent.

GENITAL AND RECTUM: Infection,discharge absent.

 INVESTIGATIONS:-
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Sl. Name of the Investigation Patient’s value Normal Value Remarks

No.
01. Serum Urea 88 mg/dl 15-40 mg/dl Increased
02. Serum Creatinine 4.42 mg/dl 0.6-1.5 mg/dl Increased
03. Serum Bilirubin 0.45 mg/dl 0.2-1.2 mg/dl Normal
04. SGPT (ALT) 25 IU/L 5-40 IU/L Normal
05. SGOT (AST) 30 IU/L 5-40 IU/L Normal
06. Serum Alkaline Phosphate(ALP) 132 IU/L 50-280 IU/L Normal
07. Serum Na+ 142 mEq/L 135-145 mEq/L Normal
08. Serum K+ 4.8 mEq/L 3.5-5.5 mEq/L Normal
09. Blood glucose (Random) 190 mg/dl Up to 140 mg/dl Increased
10. Hb% 9.8 g/dl 12-15.5 g/dl Decreased
11. HIV Non-reactive
12. HBsAg Non-reactive
13. HCV Non-reactive
14. Serum Albumin 2.5mg/dl 3-5mg/dl Decreased
15. Serum globulin 2.9mg/dl 2-4mg/dl Normal
16. Serum Cholesterol 150mg/dl 120-200mg/dl Normal
17. Serum triglyceride 137mg/dl 60-175mg/dl Normal
18. Serum HDL 48mg/dl 30-70mg/dl Normal
19. Serum VLDL
20. Serum LDL 27mg/dl 12-35mg/dl Normal
78mg/dl 70-130mg/dl Normal

Sl. Name of the Investigation Patient’s value

No.

01. Chest X-ray Normal, no infection present in the lung.

0 2. ECG Normal.
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-:DISEASE CONDITION:-

 INTRODUCTION:-
Chronic kidney disease, also called chronic kidney failure, describes the gradual loss of
kidney function. The kidneys filter wastes and excess fluids from the blood, which are then
excreted in the urine. When chronic kidney disease reaches an advanced stage, dangerous
levels of fluid, electrolytes and wastes can build up in the body.
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In the early stages of chronic kidney disease, patient have few signs or symptoms. Chronic
kidney disease may not become apparent until the kidney function is significantly impaired.
Kidney disease also increases risk of having heart and blood vessel disease. These problems
may happen slowly over a long time. Early detection and treatment can often keep chronic
kidney disease from getting worse. When kidney disease progresses, it may eventually lead to
kidney failure, which requires dialysis or a kidney transplant to maintain life.

 DEFINITION:-
 Chronic kidney disease (CKD) means kidneys are damaged and can't filter blood the way
they should. The main risk factors for developing kidney disease are diabetes, high blood
pressure, heart disease, and a family history of kidney failure.
 The disease is called "chronic" because the damage to the kidneys happens slowly over a
long period of time. This damage can cause wastes to build up in the body, CKD can also
cause other health problems.
 Chronic renal failure is a syndrome characterized by progressive and irreversible
deterioration of renal function due to slow destruction of renal parenchyma, eventually
terminating in death when sufficient number of nephrons have been damaged. Acidosis is
the major problem in CRF with development of biochemical azotaemia and clinical
uraemia syndrome.

 ANATOMY AND PHYSIOLOGY:-

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The kidneys are located on either side of the spine, in the retroperitoneal space. The left
kidney is situated a little higher than the right one, because of the liver on the right side of the
abdominal cavity, above the right kidney.

Each of the two bean-shaped organs weighs about 125 to 175 grams and 115 to 155 grams in
males and females respectively. The kidney typically measures approximately 11 to 14
centimeters in length, 6 centimeters in width and is about 4 centimeters thick. The kidneys
are protected by fat, muscles, and ribs of the back. Perirenal fat, also called the renal fat pad,
protects the kidneys from external force or damage. The kidneys have a medial dimple called
the renal hilum, which is the entry and exit point for structures that supply or drain the
kidneys such as the nerves, ureters, vessels, and lymphatics.

The most important function of the kidney is to filter the blood for urine formation. It
excretes metabolic wastes like urea and uric into the urine. It secretes a number of hormones
and enzymes such as:

Erythropoietin: It is released in response to hypoxia

Renin: It controls blood pressure by regulation of angiotensin and aldosterone

Calcitriol: It helps in the absorption of calcium in the intestinesIt maintains the acid-base
balance of the body by reabsorbing bicarbonate from urine and excreting hydrogen ions and
acid ions into the urine.

 CAUSES:-

BOOK PICTURE PATIENT PICTURE

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 Diebetes mellitus  Diebetes Mellitus

 Hypertension  Hypertention
 Obstructed urine flow  Absent
 Kidney artery stenosis  Absent
 Malaria and yellow fever.  Absent
 Certain toxins- including fuels, solvents  Absent
(such as carbon tetrachloride), and lead etc.
 Some medication- for example, NSAIDs.  Absent
 Illegal substance abuse- such as heroine or  Absent
cocain.
 Age and race  Age above 60yrs
 Kidney stones  Absent
 Family history of chronic kidney disease
 Absent
 Cardiovuscular disease
 Absent
 Infections like Hep C and HIV
 Absent

 PATHOPHYSIOLOGY:-

Due to etiological factors

Compensatory hypertrophy of surviving nephrons

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Adaptive hyper filtration & hypertrophy.

Decreased ph, k
+, nitrogenous
Loss of excretory function
waste excretion.

Like failure to
Loss of non- excretory renal function. produce
erythropoietin &
to convert
inactive form of

Sclerosis of remaining nephrons, & total function loss.

Chronic kidney failure

 CLINICAL MANIFESTATION:-

BOOK PICTURE PATIENT PICTURE

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 Tiredness, weakness, low energy  Tiredness, weakness, low energy

 Loss of appetite  Loss of appetite
 Swelling of feet, hands and ankles  Swelling of feet, hands and ankles
 Shortness of breath  Absent
 Puffy eyes  Puffy eyes
 Dry and itchy skin  Dry and itchy skin
 Trouble concentration.  Trouble concentration.
 Trouble sleeping  Trouble sleeping
 Nausea and vomiting  Nausea and vomiting
 Muscle cramps  Absent
 High blood pressure  High blood pressure
 Darkening of skin.  Darkening of skin.
 Anemia  Absent
 Decreased urine output  Decreased urine output
 Bloody urine, in some cases  Absent
 Dark urine, in some cases  Absent
 Decreased mental alertness, when  Absent
the condition is severe

 DIAGNOSTIC STUDIES:-
BOOK PICTURE PATIENT PICTURE
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 Medical History  History collection done

 Physical examination  Physical examination done
 Blood test  Blood test done
 Usg  Ultrasound
 MRI  Not done
 CT Scan  Not done
 ECG  Ecg done

 MEDICAL MANAGEMENT:-
BOOK PICTURE PATIENT PICTURE

 Tab. Farxiga  Not given

 Tab. Kerendia
 Inj.Ondem
 Tab. Dapagliflozin
 T. BCT
 Inj. Lasix
 Inj. Lantus
 Tab. Finerenon
 Tab. Jardiance
 Inj. Taxim
 Inj.Omez
 Inj.Erythropoeitin
 Not given
 Inj.ondem given
 Not given
 T.BCT given
 Inj. Lasix given
 Inj. Lantus given
 Not given
 Not given
 Inj.Taxim given
 Inj.Omez Given
 Inj.Erythropoeitin given
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 SURGICAL MANAGEMENT:-
BOOK PICTURE PATIENT PICTURE
 Nephrectomy  Not done
 Pyeloplasty  Not done
 AV fistula access  Not done
 Renal transplantation  Not done

 NURSING MANAGEMENT:-
Nursing theorists and their work have a significant impact on nurse education and clinical practice.
They can be applied both in theoretical research and used practically in diverse interventions
aimed at the improvement of patient care quality and patient outcomes. One of the theories most
commonly employed in practice is Dorothea Orem’s Self-Care Deficit Theory of Nursing. Orem
received her nursing diploma in the 1930s and started her career at Providence Hospital School of
Nursing in Washington (Berbiglia&Banfield, 2014). In the following decades, she received her BS
and MS degrees in Nursing Education. She worked throughout the country following her goal to
improve nursing in general hospitals. She is also known for developing a definition of nursing
practice and a significant contribution to the nurse education curriculum (Berbiglia&Banfield,
2014). Orem was conferred with many rewards such as the honorary degree of Doctor of Science
(1976), the CUA Alumni Association Award for Nursing Theory(1980), etc.

Theory application
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Mr.Anil Mitra was admitted in the hospital for the first time. He was very weak and aged, so
he can’t do care himself due to his condition. He needs support from others to perform daily
living activities. So, I applied Dorothea Orem’s Self-Care Deficit Theory for my patient while
caring him to improve his health status by setting the goals with both the nurse and the
patient’s mutual understanding.

According to Dorothea Orem the conceptual framework is-

In my patient’s condition the framework are as following:

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Self-care

R R

Self-care capabilities Therapeutic self-care

(self-care agency) demand
 Limited activity
R  Activity
 Decrease urine output
 Urinary output
 Swelling in
hands,feet,ankles  Infection
<
 Risk of infection

R R

Nursing capabilities
(Nursing agency)
 Improve the level of
activity
 Maintain the
balance between
intake and output
 Maintain proper
personal hygiene

 NURSING ASSESSMENT SHEET:

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Problems Need Nursing Diagnosis

 Excessive fluid  Maintain fluid volume  Excess fluid level related to

volume level decrease GFR rate and sodium
retention as evidenced patient,s
edematous hands,legs and ankles.

 Decrease activity  Improve the activity  Activity intollerence related to

level level weakness as evidenced by
inability to walk.

 Imbalance nutrition  Improve nutrition level  Imbalanced nutrition less than

level body requirement related to
inadequate nutritional intake as
evidenced by patient are looking
weak.

 Impaired skin  Improve the skin  Impaired skin integrity related to

integrity condition fluid accumulation in body parts
as evidenced by patient’s skin
condition.
 Self-care deficit  Improve the quality
 Self-care deficit: bathing, dressing,
daily living activity
toileting related to
hemiparesis/weekness.

 Risk for infection related to

 Risk of infection  Reduce the risk of
dialysis site.
infection

 NURSING CARE PLAN:

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Assessment Diagnosis Goal Intervention Implementation Evaluation

Subjective Excess fluid To - Assess the general - Assessed the Patient’s

data: level related reduce condition of the general condition fluid volume
Patient’s to decrease or patient. of the patient. level reduce
complaints that GFR rate maintai - Monitor vital signs. - Monitored vital or maintain
he has fluid and sodium n the signs. gradually.
- Monitor intake
accumulation retention as fluid
output chart. - Monitored intake
in hands, feet, evidenced volume
- Administer output chart.
ankles, patient,s level.
medicine as per - Administered
abdomen. edematous
doctor’s order. medicine as per
hands,legs,
- Dialysis should be doctor’s order.
Objective abdomen,
done as per - Dialysis done as
data: ankles.
doctor’s order. per doctor’s
Patient’s
order.
hands, feet,
ankles are
edematous.

Assessment Diagnosis Goal Intervention Implementation Evaluation

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Subjective Activity To - Assess the general - Assessed the Patient,s

data:- intollerence improv condition of the general condition activity level
Patient,s related to e the patient. of the patient. impove.
complaints that weakness as activity - Check vital signs. - Checked vital
he is feeling evidenced level. - Administer signs.
weak. by inability medicines as per - Administered
to walk. doctor,s order. medicines as per
Objective - Provide proper doctor,s order.
data:- nutrition to the - Provided proper
Patient is patient. nutrition to the
looking weak - Provide back care, patient.
and tired. 2-3 times in a day. - Provided back
- Give physiotherapy care, 2-3 times in a
to the patient every day.
day. - Given
physiotherapy to
the patient every
day.

Assessment Diagnosis Goal Intervention Implementation Evaluation

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Subjective - Assess the self care - Assessed the self Patient’s

data:- Self-care Improv level of the patient. care level of the personal
Patient deficit: e or - Encourage the patient. hygene
relatives bathing, maintai family to provide - Encouraged the maintained
complaints that dressing, n the clothing a size family to provide properly.
he has toileting persona larger than patient clothing a size
difficulty in related to l wears, with front larger than patient
self care hemiparesis hygiene closures, and stretch wears, with front
activity. /weekness. . fabric closures, and
- Teach the patient stretch fabric
relatives to dress the - Tought the patient
Objective patient while sitting relatives to dress
data: to maintain balance. the patient while
Patient is - Make sure personal sitting to maintain
unhygienic. care items, urinal, balance.
and commode are - Provided personal
nearby and that care items, urinal,
patient obtains and commode are
assistance with nearby and that
transfers and other patient obtains
activities as needed. assistance with
transfers and other
activities as
needed.

 NURSES NOTE:-
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Sl. Date Time Activity Performed Remarks

No
.
01 29/09/23 9am-  Bed making done. Patient feels
1:00pm  Monitored vital signs. comfort.
 Administered medications.

 Bed making done.

02 30/09/23 9am-  Monitored vital signs.
1:00pm  Administered health education about Gain little
the disease and treatment process. knowledge about
her disease and
treatment process.
 Bed making done.
 Monitored vital signs.
03 01/10/23 9am-
1:00pm  Provided psychological support to the Patient feels better.
patient.
 Maintained I/O chart.

 PROGNOSIS:-
1st day care:

 Provided clean and tidy bed.

 History collection was done.
 Physical examination was done.
 Checked the vital signs.
 Maintained IO Chart.
2nd day care:

 Provided clean and tidy bed.

 Physical examination was done.
 Checked the vital signs.
 Given back and hair care.
 Provided medication as per doctor’s order
 Dressing done

3rd day care:

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 Provided clean and tidy bed.

 Physical examination was done.
 Checked the vital signs.
 Back care given.
 Provided proper nutrition to the patient.

 HEALTH EDUCATION:-

Nutrition and dietary pattern:-

Provide nutrious diet to the patient.

Advice the family members give proper position to the patient before givig food.

Provide liquid diet to the patient.

Personal hygiene:

 Advised the patient and family members to wash hands before and after touching the
dialysis site.
 Advised the patient to brush the teeth twice a day.
 Advised the patient to wash clothes regularly

Exercise:

 Encouraged the patient to do some active and passive exercise.

 Advice the patient to do deep breathing exercise.

Medication:

 Advised the patient to take medicine at proper time without forgetting.

 Encouraged the patient to complete the full dose as ordered by the physician/surgeon.

Follow up care:

 Advised the patient to come for regular check-up.

 Advised the family members to provide psychological support to the patient.

RESEARCH FINDINGS:-
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Epidemiology and risk factors of chronic kidney disease in India - results

from the SEEK (Screening and Early Evaluation of Kidney Disease) study
Ajay K Singh Et Al.

Abstract

Background: There is a rising incidence of chronic kidney disease that is likely to pose
major problems for both healthcare and the economy in future years. In India, it has been
recently estimated that the age-adjusted incidence rate of ESRD to be 229 per million
population (pmp), and >100,000 new patients enter renal replacement programs annually.

Methods: We cross-sectionally screened 6120 Indian subjects from 13 academic and private
medical centers all over India. We obtained personal and medical history data through a
specifically designed questionnaire. Blood and urine samples were collected.

Results: The total cohort included in this analysis is 5588 subjects. The mean ± SD age of all
participants was 45.22 ± 15.2 years (range 18-98 years) and 55.1% of them were males and
44.9% were females. The overall prevalence of CKD in the SEEK-India cohort was 17.2%
with a mean eGFR of 84.27 ± 76.46 versus 116.94 ± 44.65 mL/min/1.73 m2 in non-CKD
group while 79.5% in the CKD group had proteinuria. Prevalence of CKD stages 1, 2, 3, 4
and 5 was 7%, 4.3%, 4.3%, 0.8% and 0.8%, respectively.

Conclusion: The prevalence of CKD was observed to be 17.2% with ~6% have CKD stage 3
or worse. CKD risk factors were similar to those reported in earlier studies.It should be
stressed to all primary care physicians taking care of hypertensive and diabetic patients to
screen for early kidney damage. Early intervention may retard the progression of kidney
disease. Planning for the preventive health policies and allocation of more resources for the
treatment of CKD/ESRD patients are imperative in India.

CONCLUSION:-
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As per my clinical posting I had posted in the Dialysis ward and during my posting I got a
patient with chronic kidney disease. He was sufferinf decreased urine output,nausea,
vomiting, weakness, edema in hands legs,abdomen etc. I have given care as per the need of
the patient and it will help me to deal with the same kind of patient in future.

REFERENCES:

1. Lewis SL. “Medical-Surgical Nursing”. 11th ed. New Delhi: Reed ELSEVIER India
Private Limited; 2015. P.
2. Hinkle JL, Cheever KH. “Brunner and Suddarth’s. Textbook of Medical-Surgical
Nursing”. New Delhi: Wolters kluwer (India) Pvt Ltd; 2019.P.
3. Ansari J. Kaur D. “A Text Book of Medical –Surgical Nursig –I”. Bikrampura:
S.Vikas & Company (Medical Publishers) India; 2015. P.

4. TNAI. Medical Surgical Nursing: A Nursing Process Approach. 1 st ed. New

Delhi:Trained Nurses Association of India; 2013. P.

5. Journal: Author-Ajay K Singh, Et Al “Epidemiology and risk factors of chronic

kidney disease in India - results from the SEEK (Screening and Early Evaluation of
Kidney Disease) study. 2013 May 28;14:114
Available from- https://pubmed.ncbi.nlm.nih.gov/23714169/
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