Chronic Kidney Disease 3

OBJECTIVES
General Objective:
Within the exposure in the area, the group would be able to present a comprehensive
and complete case study which explains the disease itself, treatment and the suitable
nursing management regarding the condition of the chosen patient.
Specific Objectives:
After the study, the students will be able to:
COGNITIVE:
1. Identify the cause of the disease.
2. Should be able to differentiate the normal and abnormal Laboratory findings.
3. Identify the effects of the drugs administered on the disease process.
4. Present an applicable nursing management that will meet the needs of the
client.
PSYCHOMOTOR:
1. Gather reliable information about the patients condition through research and
interview.
2. Conduct a thorough Cephalocaudal assessment.
3. Execute accurate nursing interventions.
AFFECTIVE:
1. Establish rapport among the group as well as the patient.
2. Enhance patience and perseverance as the preparation for the case takes place.
3. Learn to develop a sense of truthfulness and responsibility.
Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia
Page 1
INTRODUCTION
Chronic kidney disease (CKD) is an umbrella term that describes kidney damage or a
decrease in the glomerular ltration rate (GFR) for 3 or more months (Thomas-Hawkins
& Zazworsky, 2005). CKD is associated with decreased quality of life, increased health
care expenditures, and premature death. Untreated CKD can result in end-stage renal
disease (ESRD) and necessitate renal replacement therapy (dialysis or kidney
transplantation). Risk factors include cardiovascular disease, diabetes, hypertension,
and obesity. Recent research reported that 16.8% of the U.S. population aged 20 years
and older have CKD (Centers for Disease Control and Prevention [CDC], 2007).
Diabetes is the primary cause of CKD. Between 25% and 40% of patients with type 1
diabetes and 5% to 40% of those with type 2 diabetes develop kidney damage (Thomas
& Atkins, 2006). Diabetes is the leading cause of renal failure in patients starting renal
replacement therapy. The second leading cause is hypertension, followed by
glomerulonephritis and pyelonephritis; polycystic, hereditary, or congenital disorders;
and renal cancers (U.S. Renal Data System [USRDS], 2007).
2016 U.S statistics released by the WHO show that 1/10 is diagnosed with CKD. In
South East Asia, CKD cases are alarming, often leading to death. About 3/10 diagnosed
with CKD die of renal insufficiency.
According to the 2011 US Renal Data System (USRDS) data, in the year 2009,
hypertensive nephropathy (HN) accounted for 28% of patients reaching end-stage renal
disease (ESRD). The rate of ESRD attributed to hypertension has grown 8.7% since the
year 2000. Hypertensive nephropathy is reportedly the second most common cause of
ESRD in white people (23%) and is the leading cause of ESRD in black people (46%).
2015 U.S statistics released by the WHO revealed that 3/10 women are diagnosed with
this disease. Internationally, including the Philippines, 30% of the total population has
anemia secondary to other diseases such as
Page 2
II
PATIENTS PROFILE
Name:
Riri
Address:
Pasay City
Age:
68 years old
Birthday:
July 22, 1949
Birthplace:
Pasay City
Nationality:
Filipino
Sex:
Female
Civil Status:
Widowed
Religion:
Roman Catholic
Date and Time of Admission:

Admitting Diagnosis:
November 24, 2016 / 7:34 pm
Chronic Kidney Disease secondary to diabetic,

Hypertensive Nephropathy; Anemia
Attending Physician:
Dr. Pidlaoan
Hospital No:
OP
Page 3
III
PATIENTS MEDICAL HISTORY
History of Present Illness
10 years prior to admission, Riri was brought at the Pasay City General
Hospital Emergency Room, she experienced difficulty of breathing, nape pain,

and she noticed that she has an edema. Upon assessment, Riri was
hypertensive, and noted with grade 1 bipedal edema and scheduled for
laboratory test that she cant recall what tests had done, she should be put under
observation as advised by the ER staff, but she refused because she was too
anxious to know what her condition is. She was given some medications such as:
Furosemide 40 mg/tab PO OD to relieve her edema on that day and Catapres 75
mg/tab to be taken sublingually if her blood pressure reaches 150/100 mmHg.
She visits the health center to check her blood pressure whenever she feels
dizzy or nape pain. She didnt go to the doctor for consultation for the past 8
years, because until then, shes still anxious to know the result, but she still
comply with her medication maintenance for high blood which is the Catapres.
2 years prior to admission, Riri experienced difficulty of breathing, high

body temperature, and swelling feet as seen by her daughter. She was pushed
by her daughter to visit the hospital, so as she did. Upon assessment in the
PCGH, Riri was noted grade 2bipedal edema and was scheduled for laboratory
test such as UA, CBC, and Creatinine level. Creatinine result revealed high level
and was diagnosed with Chronic Kidney Disease. The doctor advised her to
undergo dialysis but again she refused but still she complied with the
medications given.
7 days prior to admission, she had been experiencing nape pains,

dizziness and stated that she took Catapres after her BP reached 150/100
mmHg and took rest until the symptoms subsided. During this span of time, Riri
did not seek medical consultation.
2 days prior to admission, Riri experienced difficulty of breathing and her

edema worsened but she did not seek medical consultation.
Page 4
One day prior to admission, she had been experiencing nape pains,
dizziness and swelling of feet. Her two years partner in life pushed her to seek
medical consultation because they were both curious.
One day prior to admission, she went to Pasay City General Hospital
Emergency Department, she complained nape pains, dizziness, restlessness
and swelling of both feet. Vital signs are as follows, BP: 180/100 mmHg for 3
consecutive readings, RR: 28 cpm, T: 35.5 oC. She was then scheduled for
laboratory tests; CBC, UA, ABG Analysis and. Blood Chemistry results showed
increased levels in Riris Creatinine 1093.1 mol/L, BUA 480 mol/L, BUN 39.6
mg/dL, UA results showed +2 protein, and ABG results revealed metabolic
acidosis. Hence, admitted at the Female Medical Ward @ 7:34 pm of November
24, 2016.
b
Past Medical History

On the fifth pregnancy of Riri, she was diagnosed with gestational
diabetes mellitus at Philippine General Hospital and she underwent Cesarean

Section when she gave birth.
Family Medical History
Father
Mother
Page 5
Sister 1
Brother 2
Sister 3
Patient Riri
Brother 5
Legend:
-
Deceased
Diabetes Mellitus
Hypertension
Kidney Disease
Heart Disease
d
Social History
Riri is a housewife from her past relationships (married twice and both of them
passed away) until now (2 years cohabitating with her new partner). She seldom
spends her time with her children, because they all have their own family already.
Riri doesnt go out often to mingle with her neighbors because she said she
wants to rest and she wont waste her time on worthless gossips. Riri used to
drink alcohol beverages occasionally when shes young and doesnt engage in
cigarette and drug use.
e
Environmental History
Riri resides in Pasay, owned by his current partner. Their environment is
congested. It is a bungalow house, with 1 room, two windows and 1 door. The
house is made up of concrete materials and the roof is galvanized, has an
electric supply and has sufficient lightings. The households water supply is level
3 (NAWASA) and they store water in a drum with cover. They use mineral water
for drinking and tap water for households. They use a refrigerator to store their
left over. Their garbage disposal method was collected and they place their
garbage in a container without cover, they do not practice waste segregation.
Their waste disposal is water sealed.
f
Developmental History
Erik Eriksons Psychosocial Theory
Integrity vs Despair
Page 6
STAGE
AGE GROUP
NORMAL
ACTUAL
FINDINGS
FINDINGS
I
ntegrity vs
Despair
65+
As senior citizens,
According to Riri,
people tend to
when she became
look back on their
a mother, she had
lives and think
been contented in
about what they
being a
have or have not
housewife,
accomplished. If a
because in that
person has led a
way, she got to
productive life,
took care of her
they will develop a
husband and
feeling of integrity.
children, for her
If not, they might
its one of her
fall into despair.
biggest
achievement as a
wife and mother.
Her four
daughters
graduated college
(2 in education
and 2 in HRM)
and her 3 sons is
high school
graduate. She
stated that she is
blessed, because
all of the partner
she had, cares for
Page 7
her and accept

her.
Now she said that
she has no regrets
in life, living and
creating happy
memories with her
new partner.
Sigmund Freuds Psychosexual Development Theory

Genital
STAGE
Genital
AGE GROUP
12+
NORMAL
ACTUAL
FINDINGS
FINDINGS
During this stage,
According to Riri,
sexual impulses
she got married
reemerge. If other
twice, and had 3
stages have been
children from her
successfully met,
first husband and
adolescents
4 children from
engage in
her second
appropriate sexual
husband, and both
behavior, which
of her husbands
may lead to
had passed away.
marriage and
Now, she has a
childbirth.
partner and had
Page 8
been cohabitating
for two years.
According to her,
she is now
sexually inactive.
OB Score: G7P7
Menarche: 13 years old
Interval: Her period is regular, every 29 days
Duration of menstrual period: 5 6 days
Amount: She uses 3 4 overnight pads / day
Saturation: Her pads are heavily soiled during her 1 st to 3rd day and slightly
soaked during her 4th to 6th day.

Onset of sexual intercourse: 19 years old
Page 9
IV
GORDONS FUNCTIONAL PATTERN
Pattern
Prior to
During
Analysis/
Hospitalization
Hospitalization
Interpretation
Health Perception
Riri is known
Riri is still
Riri becomes more
and
hypertensive since
hypertensive
aware on her food
Health
2006 and was
preferences and
Management
prescribed with
follows doctors
Pattern
Catapres as her
advices and health
maintenance.
teachings given.
She was also
She is already
prescribed Furosemide
complying to doctors
10 years prior to
advises and
admission for her
prescriptions
grade 1 bipedal
edema, when she was
brought to PCGH.
2 years prior to
admission, she was
rushed to PCGH. Her
creatinine result
revealed high level and
was diagnosed with
CKD. The doctor
advised her to undergo
dialysis but she
refused.
Page 10
Riri has no known

allergies.
Nutritional
Riri ate 5 times a day
She ate 5 times a
Her eating pattern
day.
didnt change but
She doesnt have food
Her diet turned into
the food
restrictions.
blunt diet
preferences are
Metabolic Pattern
already limited and

She drinks about 6-8
Her fluid intake is
her fluid intake had
full glasses of water a
ranging from 500-
decreased.
day.
1000cc a day, that

includes oral and IV
fluids, which is equal
to 2-4 full glasses a
day.
Elimination Pattern
Riri urinates 3-4 times
Riri urinates 2-3
Her elimination
a day and defecates
times a day
pattern changed.
five times a week
(measured. ranging
Her urine output is
from 300-500cc a
low, because she is
day) and defecate 3
experiencing water
times a week.
retention.
Activity- Exercise
Riri doesnt engage in
Riri is now living in a
Riris activity level
Pattern
any form of exercise,
sedentary lifestyle;
decreased.
and perceives doing
she seldom stands
household chores as a
up and walks around.
form of exercise.
Sleep-Rest Pattern
She usually sleeps
She sleeps 8 hours a
Sleeping pattern
12hrs a day
day
had changed due to
Page 11
interruptions
whenever she
needs to undergo
tests or performs
procedures given by
health care
provider.
Cognitive-
She has no difficulty
She has no difficulty
Perceptual Pattern
with her hearing but
with her hearing but
has difficulty with her
has difficulty with her
hearing but has
hearing but has
difficulty with her
difficulty with her
vision. No changes in
vision. No chnges in
taste and smell.
taste and smell.
Vision had
changed due to her
old age and her
due to her disease
condition.
Show normal
cognition and
Able to communicate
Able to communicate
with verbal and non-
with verbal and non-
verbal cues.
verbal cues.
She is oriented about
She is oriented about
the time, day, and
the time, day, and
scenarios
scenarios
Role-Relationship
Pattern
She had been married
perception.
She was oriented.
In a relationship with
She said, engaging
her third partner.
in a relationship is
twice but both of them
her way to have
died, and have had a
someone to be with
relationship 2 years
and have someone
ago until now.
to take care of her.
Page 12
Her siblings visited
She still has
She has 7 children, 3
her during
communication and
children from her first
hospitalization.
connections to her
husband and 4
family members.
children from her

second husband,
those siblings already
has their own family
and does not reside in
her side.
Sexuality
Riri menarche started
Reproductive
when she was 13
Pattern
years old.
Sexually inactive
Sexually inactive
Riri had her 1st coital at

the age of.
19
Riris menstrual period
is regular and
consumes 3 to 4 pads
a day.
She cant recall when
she had her last
intercourse.
Coping Stress
According to her, she
Still by talking to her
They were still on
Tolerance Pattern
copes to stress by
partner but wasnt
the basic self stress
talking to her
able to make crochet
coping technique.
husband/partner.
anymore.
Page 13
She also makes

crochet as her past
time.
Value-Belief
She is a Roman
Riri has not been
She has strong faith
Pattern
Catholic.
able to go to church
in God despite her
since she got
present state.
She seldom goes to
hospitalized, but she
church but she always
never forgot to pray
pray at home.
for herself and safety

of her family.
PHYSICAL ASSESSMENT (November 28, 2016 )
AREA ASSESSED
General
Appearance
METHOD
NORMAL
ACTUAL
USED
FINDINGS
FINDINGS
Well Groomed
Well groomed
and behaves
Inspection
REMARKS
Normal
Behaves
according to
Page 14
According to her
her age
age
Skin
Color
Uniformity of
Inspection
Inspection
skin color
Varies from light
Pale
Due
to
to deep brown,
decreased
from ruddy pink
Hgb(89g/L),
to light pink,
Hct(0.27), and
from yellow
RBC
overtones to
levels(2.90x10
olive
12
/L).
Generally
Generally, the
Due
to
uniform except
skin of the
decreased
in areas
patient is pale
Hgb(89g/L),
exposed to the
Hct(0.27), and
sun, areas of
RBC
lighter
levels(2.90x10
pigmentations
12
/L).
(palms, lips and

nail beds).
Moisture
Moisture in the
Skin is dry
Due to grade 3
Inspection;
skin folds and
and shiny in
bilateral
Palpation
the axilla (varies
appearance.
edema
on
with
upper
and
environmental
lower
Page 15
temperature and
extremities.
humidity, body
temperature and
activity)
Turgor
Inspection
Skin get back
Skin get back
Due to grade 3
normal when
less than a
bilateral
pinched
minute when
edema
on
pinched.
upper
and
lower
extremities.
Epidermis
Palpation
Thickness
Epidermis is
appears to be
Due to grade 3
uniformly thin
thick on both
bilateral
over most of the
upper and
edema
on
body
lower
upper
and
extremities as
lower
well as the
extremities.
facial area
Due to grade 3
bilateral
Tenderness
Palpation
Skin surfaces
are non-tender
Skin surfaces
edema
on
are tender
upper
and
lower
extremities.
Page 16
Caused
(+) hematoma extraction
Hematoma
Inspection
Inspection
of
Absence of
on the right
blood
and
hematoma
arm, about
saving the left
2cm in
arm
diameter.
ordered.
as
Due
Edema
by
to
(+)grade 3
accumulation
Absence of
bilateral
of fluid caused
edema
edema in
by
both upper
hydrostatic
and lower
pressure
extremities.
resulting
increased
to
shifting of fluid
to
the
extravascular
space
Hair
Distribution
Inspection
Evenly
Evenly
distributed over
distributed
the scalp
over the scalp
Normal
Page 17
With straight,
Texture
Palpation
Fine or thick
thick hair
Normal
hair; straight,
curly or kinky;
silky, resilient
hair
Gray Color
Color
Inspection
Black color or
Normal
gray color,
considering the
age
Nails
Appearance
Inspection
Clean nails
Clean nails
Normal
Color of the
Inspection
Pink
Pale
Due
nailbed
to
decreased
Hgb(89g/L),
Hct(0.27), and
RBC
Capillary
Palpation
refill time
Return within 2-
Return within
levels(2.90x10
3 seconds
5 seconds
12
Rounded,
Rounded,
Normal
smooth skull
smooth skull
contour
contour
/L).
Head
Shape and
size
Inspection
Page 18
Facial
Inspection
features
Symmetric or
Symmetric
slightly
asymmetric
facial features
Symmetry of
Inspection
facial
Symmetric facial
Symmetric
movements
facial
features
movements
Ears
Auricle
Position
Texture
Inspection
Inspection
At the level of
At the level of
the external
the external
cantus of the
cantus of the
eyes
eyes
Smooth, without
Smooth,
lesion
without lesion
Normal
Normal
External Auditory
canal
Discharges
Inspection
None
None
Normal
Color of
Inspection
Pink
Pink
Normal
canal walls
Nose
Page 19
Color
Inspection
Same color with
Same color
the face
(pale) with the
Normal
face
Sinuses
Inspection
Not inflamed
Not inflamed
Normal
Nares
Inspection
No obstruction;
No
Normal
oval and
obstruction;
symmetric
oval and
symmetric
Lesion/
Palpation
Tenderness
Not tender,
Not tender,
absence of
absence of
lesion
lesion
Symmetrical
Symmetrical,
Normal
Lips
Symmetry
Inspection
Normal
Due
Color
Inspection
Pinkish
Pale
to
decreased
Hgb(89g/L),
Hct(0.27), and
RBC
levels(2.90x10
12
/L).
Neck
Page 20
Position
Inspection
Centrally
Centrally
located on the
located on the
shoulder
shoulder
Normal
- with
Femoral
Normal
Catheter on
the right side
Movement
Inspection
Able to flex
Able to flex and
and extend
extend head
head without
without pain and
pain and
resistance
resistance
Lymph nodes Palpation
Normal
Not palpable
Not palpable
Thorax and Lungs

Anterior thorax and
lungs
Breathing
patterns
Inspection
Quiet, Rhythmic
Pt. has
Due to grade 3
and Effortless
difficulty of
bilateral
Respiration
breathing, (+)
edema
use of
upper
accessory
lower
muscles
extremities
of
and
Page 21
(RR: 28 bpm)
Symmetry
Inspection
Symmetrical
Symmetrical
Normal
Lung breath
Auscultation
sounds
No adventitious
No
sound
adventitious
Normal
sound
Heart
Rate
Rhythm
Auscultation
Regular rate(60-
Regular
Normal
100)
rate(78bpm)
Auscultation
no murmur
no murmur
Normal
Inspection
Flat, rounded
Flat, rounded
Normal
Inspection
Equal size
Edema on
Due to grade 3
upper and
bilateral
lower
edema
extremities
upper
Abdomen
Contour
Upper & lower

extremities
Size
of
and
lower
extremities
Symmetry
Inspection
Symmetrical
Symmetrical
Distribution
Inspection
Evenly
Evenly
Normal
Page 22
of hair
Skin color
Inspection
distributed
distributed
Normal
Light to deep
Pallor
Due
brown
to
decreased
Hgb(89g/L),
Hct(0.27), and
RBC
levels(2.90x10
12
/L).
Musculoskeletal
ROM
Inspection
Full ROM
Unble to flex
Due
to
against gravity,
and extend,
weakness
full resistance,
abduct,
bones
5/5
adduct,
muscles
plantar and
secondary
dorsiflexion of
aging
the
of
and
to
the lower and

upper
extremities
Page 23
Date Performed: November 28, 2016

Vital Signs
8:00 am
12:00 pm
Pulse Rate
Respiratory Rate
Temperature
Blood Pressure
78 bpm
28 bpm
35.4oC
160/100 mmHg
84 bpm
24 bpm
35.2oC
170/90 mmHg
Input and Output

Date
Nov. 25, 2016
Nov. 26, 2016
Nov. 27, 2016
Oral
300cc
500cc
900cc
IV
180cc
150cc
150cc
Urine
500cc
450cc
300cc
BM
2x
1x
-
CBG Monitoring (Nov. 27, 2016)

Time
6:00am
11:00am
5:00pm
VI
Result
108mg/dl
146mg/dl
184mg/dl
ANATOMY AND PHYSIOLOGY

RENAL SYSTEM
The
kidney are
bean-shaped,
highly
vascular
organs
that
measure
Page 24
approximately
(11.4cm)
long
and
(6.4cm)
wide.
Located
retroperitoneally, they lie on either side of the vertebral column, between the 12 th
thoracic and 3rd lumbar vertebrae. Here, the kidneys lie protected, behind the
abdominal content and in front of the muscle attached to the vertebral column. A
perirenal fat layer offers further protection.
The ureters, acts as ducts to allow urine to pass from the kidney to the
bladder. They measure about 10 to 12 (25 to 30cm) long in adults and have a
diameter varying from 2 to 8cm, with the narrowest portion being at the
ureteropelvic junction. Because the left kidney is higher than the right one, the
left ureter typically is slightly longer than the right one.
The bladder is a hallow, spherical, muscular organ in the pelvis that
serves to store urine. It lies anterior and inferior to the pelvic cavity and posterior
to the symphysis pubis. Bladder capacity ranges from 500 to 600ml in a normal
adult, less in children and elderly people. If the amount of stored urine exceed
bladder capacity, the bladder distends above the symphysis pubis. The base of
the bladder contains three opening that form a triangular area called the trigone.
The urethra is a small duct that channels urine outside the body from the
bladder. It has an exterior opening termed the urinary (urethral) meatus. In the
female, the urethra ranges from 1 to 2 2.5 to 5cm) long, with the urethral
meatus located anterior to the vaginal opening.
Renal Blood Flow
The kidney receive approximately 1 L of blood per minute-one-fifth of the
cardiac output. This high rate of blood flow is not required for meeting
extraordinary energy demands, but for allowing the kidney to adjust the blood
composition continually. By adjusting the blood composition, the kidney Is able to
maintain blood volume; ensure sodium, chloride, potassium, calcium, phosphate,
and pH balance, and eliminate products of metabolism such as urea and
creatinine.
Page 25
Blood flows to the kidney via the renal arteries, one renal artery to each
kidney. In the kidney, the renal artery branches any times, ending as several
afferent arterioles. Each afferent arteriole become the glomerular capillary that
supplies a nephron with blood.
The glomerular capillary reforms not to become a venule as most
capillaries do, but to form the efferent anteriole. The efferent anteriole soon
branches in to a second capillary network, the peritubular capillaries, which
surround and support the nephron tubules themselves. At the end of each
nephron the peritubular capillaries finally reform to venules. The venules joint to
become veins. Blood leaves the kidney and heads back to the venacava to be
recirculated. the peritubular capillaries surrounding the long loop of the nephron
are called the vasa recta.
Filtration, reabsoption, and secretion
Filtration refers to the bulk flow of plasma across the glomerular capillary
into the interstitial fluid space surrounding the start of the nephron, an area called
Bowmans space. At the glomerulus, approximately 20% of the plasma is
continually filtered into bowmans space.
Most of the substance that enter the tubule at bowmans capsule do not
remain in the tubule. Instead, they move back into the blood across the
peritubular capillaries by the process of reabsorption. Others substance are
added to the urine filtrate, also across the peritubular capillaries, by the process
of secretion. It is by reabsorption and secretion that the nephrons manimulate the
composition and volume of the initial urine filtrate to produce the final urine.
Glomerular filtration
Page 26
Glomerular filtration is the process by which approximately 20% of the
plasma entering the glomerular capillary moves across the capillary into the
interstitial space and from there into bowmans capsule. Neither red blood cells
nor plasma proteins are more than minimally filtered in healthy kidney.
The process of filtration across the glomerulus is similar to that which
occurs across all capillaries. What is different in the kidney is that the glomerular
capillaries have increased permeability to small solutes and water. Also, unlike
other capillaries, the forces favoring filtration of plasma across the glomerular
capillary into a bowmans space are greater than the forces favoring reabsorption
of fluid back into the capillary. Therefore, net filtration of fluid into bowmans
space occurs. This fluid then diffuses into bowmans capsule and begin its
journey to the res of the nephron.
In the glomerulus, the primarily force favoring filtration is capillary
pressure. In most other capillaries, this pressure average 18mmHg; in the

glomerulus the average pressure is almost 60mmHg. This high capillary pressure
occurs as a result of decresed resistance to flow offered by the afferent arteriole
feeding the glomerulus, compared with arterioles elsewhere. Therefore, the
hydrostatic pressure reaching the glomerulus is greater.
Interstitial fluid pressure in bowmans space is also much greater than in
normal interstitial space (approximately 15mmHg vs approximately 3 mmHg).

This greater pressure is a result of the high fluid volume entering bowmans
space from the glomerulus, thus opposing further glomerular filtration. Capillary
concentration of protein is the same in the glomerulus as in other capillaries. The
plasma colloids osmotic pressure increase throughout the length of the
glomerulus as protein free filtrate pushed into bowmans space, averaging
approximately 28mmHg overall; this force opposes glomerular filtration. The
interstitial fluid colloid osmotic pressure is normally approximately 8mmHg; this
pressure favors glomerular filtration.
Page 27
Measurement of glomerular filtration rate
GFR measurement is possible if one has a substance (call it x) that is
freely filterable at the glomerulus and then is not reabsorbed, secreted, or

change in anyway before it appears in the urine to calculate the GFR from the
substance, one would measure its concentration in a plasma sample (Px), is
concentration in the urine sample (Ux), and the urine volume over a certain
period of time (V). given this values, the equation for GFR, in millimeters per
minute, can be solved as shown:
GFR (mL/min)= Ux (mg/mL)V(mL/min)
Px(mg/mL)
Page 28
CIRCULATORY SYSTEM
While
many
view
the
circulatory system, also known as the cardiovascular system, as simply a

highway for blood, it is made up of three independent system that work together;
the heart (cardiovascular); lungs (Pulmonary); and arteries, veins, coronary and
portal vessels (systemic), according to the U.S National Library of Medicine
(NLM).
The heart, blood, and blood vessels make up the cardiovascular
component of the circulatory system. It includes the pulmonary circulation, a loop

though the lungs where blood is oxygenated. It also incorporates the systemic
circulation, which runs through the rest of the body to provide oxygenated blood,
according to NLM.
Page 29
The pulmonary circulatory system sends oxygen-depleted blood away
from the heart though the pulmonary artery to the lungs and returns oxygenated
blood to the heart though the pulmonary veins.
The systemic circulation is the portion of the circulatory system is the
network of veins, arteries and blood vessels that transports blood from heart,
services the bodys cells and then re-enters the heart.
Another circulatory disease, hypertension commonly called high blood
pressure causes the heart to work harder and can lead to such complications
as a heart attack. A stroke, or kidney failure.
Part of the Circulatory System

The circulatory System is divided into three major parts:
1. The heart
2. The blood
3. The blood vessels
The heart
The heart is an amazing organ. The heart beat about 3 Billion times during
an average lifetime. It is a muscle about the size of your fist. The heart is located
in the center of your chest slightly to the left. Its job is to pump the blood and
keep the blood moving throughout your body.
Red Blood Cells
Red Blood Cells are responsible for carrying oxygen and carbon dioxide.
Red blood cells pick up oxygen in the lungs and transport it to all body cells. After
delivering the oxygen to the cells it gathers up the carbon dioxide (waste gas
produced as our cells are working) and transport carbon dioxide back to the
lungs where it removed from the body when we exhale (Breath out). There are
about 5,000,000 Red blood Cells in one drop of blood.
Page 30
White Blood Cells (Germinators)
White Blood Cells help the body fight off germs. White Blood Cells attack
and destroy germs when they enter he body. When you have an infection your
body will produce more White Blood Cells to help fight an infection. Sometimes
our White Blood Cells need a little help and doctor will prescribe an antibiotic to
help our White Blood Cells fight a large scale infection.
Platelets
Platelets are blood cells that help stop bleeding. When we cut ourselves
we have broken a blood vessels and he blood leaks out. In order to plug up the
holes where the blood is leaking from the platelets star to stick to the opening of
the opening of he damaged blood vessels. As the platelets stick to the opening of
the damaged vessels they attract more platelets, fibers and other blood cells to
help form a plug to seal the broken blood vessels. When the platelet plug is
completely formed the wound stops bleeding.
Plasma
Plasma is the liquid part of the blood. Approximately half of your blood is
made of plasma. The plasma carriers the blood cells and other components
throughout the body. Plasma is made in the liver.
Three types of Blood Vessels.

1. Arteries
2. Capillaries
3. Veins
Arteries
Arteries are blood vessels that carry the blood away from the heart, much
of which is oxygen rich.
Page 31
Capillaries
Capillaries are tiny blood vessels as thin or thinner than the hairs on your
head. Capillaries connect arteries to veins. Food substances (nutrients), oxygen

and wastes pass in and out of your blood through the capillary walls.
Veins
Veins carry blood back toward your heart.
The pancreas is a flat, pear-shaped gland. It is behind and below the stomach. The
pancreas is part of the digestive system. It is also part of the endocrine system. The
endocrine system is the group of glands and cells in the body that make and release
hormones (which control many functions such as growth, reproduction, sleep, hunger
and metabolism) into the blood.
Structure
The pancreas is about 15 cm (6 in) long. The widest section is called the head. The
narrowest part is called the tail. The middle section is called the body.
The pancreas has a series of small tubes that drain into the pancreatic duct. The
pancreatic duct joins the common bile duct and empties into the duodenum. The
Page 32
duodenum is the first part of the small intestine that receives partially digested food from
the stomach, absorbs nutrients and passes digested food to the jejunum. The
duodenum also receives bile (a yellow-green fluid that helps digest fat) from the liver
and gallbladder.
Function
The pancreas is made up of exocrine cells and endocrine cells. These cells have
different functions.
Exocrine cells
Most of the cells in the pancreas are exocrine cells. Exocrine cells make and release
pancreatic juice. The juice travels through the pancreatic duct into the duodenum.
Enzymes in the pancreatic juice help digest fat, carbohydrates and protein in food.
Endocrine cells
A small number of the cells in the pancreas are endocrine cells. They are arranged in
clusters called islets, or islets of Langerhans. The islets make and release insulin and
glucacon into the blood. These hormones help control the level of sugar, or glucose, in
the blood.
Insulin lowers the amount of sugar in the blood when the blood sugar is high. It
stimulates the liver, muscles and fatty tissues to absorb and store the extra blood sugar.
Glucagon increases the amount of sugar in the blood when the blood sugar is low. It
stimulates the liver and other body tissues to release stored sugar into the blood.
Page 33
VII
PATHOPHYSIOLOGY
Page 34
Page 35
Page 36
VIII
LABORATORY AND DIAGNOSTICS
BLOOD TYPING RESULT (11-24-16)

ABO: A Rh: (+)
BLOOD ELECTROLYTES
Na+
RESULT
11-25-16
132.0mEq/
11-27-16
138.8mEq
/L
NORMAL RANGE
ANALYSIS
135-145mEq/L
Increased, due to depleting

GFR and aldosterone, fluid
moves in the extravascular
space
K+
3.37mEq/L
4.35mEq/
L
3.5 5.0 mEq/L
due
to
increased
hydrostatic pressure.
Became
normal
due
to
diuretics given (Furosemide)

which preventing body from
absorbing too much Na and
keeps K+ levels low.
Page 37
BLOOD CHEMISTRY (11-25-16)

Normal Values
4.10 6.40 mmol/L
44.0 80.0 umol/L
1.70-8.30mg/dL
Analysis
Normal
Increased, due to presence of
TRIGLYCERIDES 1.98mmol/L
3.90 5.20 mmol/L
waste products are not properly
BLOOD
142.0 339.0 umol/L
GLUCOSE/FBS
CREATININE
BUN
Result
4.87mmol/L
1093.1umol/L
39.6mg/dL
urea retained in the vasa recta,

excreted.
URIC 480.8umol/L
ACID
TOTAL PROTEIN
ALBUMIN
GLOBULIN
12.7
16.1g/L
26.6
66-87
35-52g/L
0-3
HDL
1.51mmol/L
0.40 1.70 mmol/L
Decreased, caused by retained

urea and other substance such
as Na in the vasa recta which
also causes proteinuria.
Normal
ARTERIAL BLOOD GAS RESULTS (11-25-16-)
Ph
paCO2
paO2
HCO3
O2 Sat
RESULT
NORMAL
7.29
28.1
109
RANGE
7.35-7.45
35-45 mmHg
80-100
14.0
98.0%
mmHg
22-26mEq/L
95-100%
INTERPRETATION
Indicates, Metabolic Acidosis due to
inability of the kidneys tubules to
excrete ammonia and to reabsorb
sodium bicarbonate.
Result
Normal Values
Analysis
Color
Yellow
Yellow
Due to presence of bacteria and protein
Transparency
Slightly
Clear
that cannot be filtered properly by the
Turbid
glomeruli, it altered the color and

transparency of the urine.
Page 38
Sugar
Protein
NEGATIVE
+2
NEGATIVE
NEGATIVE
NORMAL
Due to damage in the glomeruli and
presence of urea in the vasa recta
filtration is not properly done by the
kidneys causing proteins to leak in the

urine.
Ph
Specific Gravity
5.0
1.018
4.8-7.8
1.015-1.025
WBC/HPF
RBC/HPF
6-8/HPF
2-6/HPF
NEGATIVE
Mucus thread
NORMAL
Due to injury in the glomeruli and
presence of urea in the vasa recta

NONE
MODERATE
WBC and RBC leaks in the urine.

The epithelium is disrupted by the
bacteria which results in shedding of
causing the presence of mucus threads

Epithelial Cells
URINALYSIS (11-25-16)
in the urine.
NORMAL
FEW
HEMATOLOGY
NORMAL
DATE
VALUES
ANALYSIS
11-24-16
11-27-16
Hemoglobin
87 g/L
89 g/L
120-160 g/L
Decreased, due to failure of
Hematocrit
0.262
0.270
0.37-0.43
kidneys
RBC
2.76x1012
2.90x1012/L 4.0-5.4x1012/L
/L
to
secrete
erythropoietin, bone marrow is

not
properly
stimulated
to
produce RBC which is also

accompanied by decreased Hgb
and Hct.
Page 39
WBC
Platelet Count
Neutrophil
8.52X102/ 8.83
4.0-10.0
Normal
X102/L
X102/L
218
Adequate
150-400
Indicates that the platelet count
X102/L
is within the normal range.
0.55-0.65
Increased, indicates that theres
0.77
0.71
enough primary cells that fights

foreign
bodies
inflammation
due
brought
to
by
malfunction of the kidney.

Lymphocyte
0.13
0.18
0.25-0.35
Decreased; the body produces

sufficient lymphocytes, but they
are destroyed due to bone
marrow suppression.
Monocyte
0.05
0.03
0.02-0.06
NORMAL
Page 40

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Chronic Kidney Disease 3

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OBJECTIVES

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

July 22, 1949

Date and Time of Admission:

November 24, 2016 / 7:34 pm

Chronic Kidney Disease secondary to diabetic,

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

PATIENTS MEDICAL HISTORY

History of Present Illness

Hospital Emergency Room, she experienced difficulty of breathing, nape pain,

2 years prior to admission, Riri experienced difficulty of breathing, high

7 days prior to admission, she had been experiencing nape pains,

2 days prior to admission, Riri experienced difficulty of breathing and her

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

Past Medical History

diabetes mellitus at Philippine General Hospital and she underwent Cesarean

Family Medical History

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

when she became

look back on their

a mother, she had

lives and think

about what they

have or have not

person has led a

way, she got to

took care of her

they will develop a

children, for her

If not, they might

its one of her

fall into despair.

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

her and accept

Sigmund Freuds Psychosexual Development Theory

During this stage,

she got married

twice, and had 3

stages have been

children from her

first husband and

husband, and both

had passed away.

Now, she has a

partner and had

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

soaked during her 4th to 6th day.

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

GORDONS FUNCTIONAL PATTERN

Riri becomes more

aware on her food

2006 and was

advices and health

She was also

admission for her

Chronic Kidney Disease Secondary to Diabetic, Hypertensive Nephropathy; Anemia

Riri has no known

Riri ate 5 times a day

She ate 5 times a

Her eating pattern

didnt change but

She doesnt have food