Case Study on Chronic Kidney Disease probably to secondary hypertension

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 Stage 5 CKD is also called established chronic kidney disease and is synonymous with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).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 Self PerceptionSelf Concept Pattern Role Relationship Pattern Sexuality and Reproductive Health

Cognitive Perceptual Pattern Coping Stress Tolerance Pattern

Before Hospitalization Patient felt she is still strong

During Hospitalization Patient feels weak and wants to be out of the hospital Patient primary Patient primary support are her support are children still her children Patient Patient still believed she is believed she is too old too old

There are no problem in hearing and visual acuity Psychosocial:

There are no problem in hearing and visual acuity Psychosocial:

Ego Integrity

Ego Integrity

Vs

Vs

Despair

Despair

Psychosexual:

Psychosexual:

Genital

Genital

Cognitive:

Cognitive:

Formal Operational

Formal She still talks

Analysis and Interpretation Normal concern regarding on her body strength Patient is dependent on her children Normal reaction on sex and reproductive health because of her age Normal cognitive patterns Patients display normal psychosocial, psychosexual and cognitive development. Emotional stability

Value Belief Pattern Elimination

Activity Exercise Pattern

Sleep Rest Pattern

Safe Environment Oxygenation Nutrition

She talks to her children and friends She hear mass regularly and pray the rosary Patient use to void 4 times a day and regularly defecates at least once a day Patient prefer to walk for exercise

to her children and friends

No allergies

No allergies

Patient able to eat and finish one full course meal and able to eat any kinds of fruits,

Patient fluid is partially supplied intravenously by PNSS 1L x 10gtts/min. her

Patient seek God’s guidance for well being Patient is place in folly catheter and defecation of stool is altered

Patient has strong religious belief. Patient voiding pattern are altered due to the folly catheter inserted

Patient cannot stand nor move here extremities and sits on bed The patient The patient has an average now has of 6 hours of irregular continuous pattern of sleep sleep

Patient activity is altered because of being bedridden Interrupted sleep during hospitalization because of environmental factors and hospital procedure Normal

Iv fluids are given for hydration. Diet of the patient is restricted.

meat and vegetables. Maximum intake of fluids is 3-5 glass a day.

diet is maintain Low salt low fat and Na intake is limited. She eats 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 reabsorbed in the medulla and put back into the blood. Glomerulus and Bowman's Capsule This is where ultrafiltration 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 reabsorbed 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 Color Transparency Specific Gravity Reaction Chemical Tests Sugar Albumin

Microscopic Light yellow Cloudy 1.015 6.0 Negative

RBC WBC Epithelial Cells Mucus Threads Bacterial Crystals A. Urates

12-15 / HPF Many / HPF Moderate Few Many Many

Trace

Special Tests

A. Phosphate Calcium Coxalate

Foam’s test Ketone Pregnancy test Analysis and Interpretation:

Others

Laboratory results revealed that there is presence of albumin in the blood and no sugar present. Urinalysis August 19, 2009 Macroscopic Color Transparency Specific Gravity Reaction

Microscopic Light yellow Slightly cloudy 1.020 5.0

RBC WBC

2-3 / HPF 2-3 / HPF

Epithelial Cells

Few

Mucus Threads

Occasional

Chemical Tests Sugar Albumin

+2

Bacterial Crystals B. Urates

Few Moderate

+3

Special Tests Foam’s test Ketone

B. Phosphate Cast Others

Coarse granular 3-5 / LPF 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 Resul Normal Analysis t WBC 10.4 4.0Normal 11.0x10^9 /L RBC 2.36 4.0Result was below normal. 6.0x10^12 This indicates alteration in /L erythropoietin production secondary to renal malfunction. HGB 70 120-180 Result was below normal. g/L This shows the decrease in the oxygen carrying capacity of the blood secondary low hematocrit. HCT 0.22 0.370Result was below normal, 4 0.540 thus showing anemia related to insufficient RBC production. MCV 94.8 20-100fL Normal

MCH MCHC

29.6 312

RDW Differential count

15.2

27-31pg Normal 320-360 Result was below normal g/L 11.5-15.0% Normal

01

2-6%

Result was below normal

Bands Segmented Lymphocytes

93 05

50-70% 20-44%

Monocytes

01

2-9%

Result was above normal Result is above the normal range, indicating bacterial infection. Result was below normal

August 18,2009 Test Resul Unit t Creatini ne

674 high

u mol/ L

Sodium

133 low

mm ol/L

Potassiu m

2.5 low

mm ol/L

Normal values

Resul ts conv.

U nit

Normal values

Analysis and Interpretation

53.0 1 11.50 mg 0 1 Result was 0 .30 /dl .60 .30 above normal thus showing inability of the kidney to excrete nitrogenous waste. 136 14 122.0 mE 13 14 Result was 8 0 q/d 6 8 below normal l thus showing the fluid and electrolyte imbalance. 3.65 5 6.30 mE 3 5 Result was .20 q/d .60 .20 below normal l thus showing

the fluid and electrolyte imbalance. August 28, 2009 Test Resul Unit t

Normal values

Creatini ne

674 high

u 53.0 1 mol/ 0 .30 L

Sodium

133 low

mm ol/L

Potassiu m

2.5 low

mm ol/L

Resul t conv. 7.62

U nit

Normal values

Analysis and Interpretation

mg 0 1 Result was /dl .60 .30 above normal thus showing inability of the kidney to excrete nitrogenous waste. 136 14 133.0 mE 13 14 Result was 8 0 q/d 6 8 below normal l thus showing the fluid and electrolyte imbalance. 3.65 5 2.50 mE 3 5 Result was .20 q/d .60 .20 below normal l 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.