JMJ Marist Brothers

The Graduate School

NOTRE DAME OF DADIANGAS UNIVERITY MCMLXXXII

Marist Avenue, General Santos City Q uest for H igher L earning

Nursing 209 (Concept in Medical-Surgical Nursing) October 2016

This Case Study is published by the NDDU Graduate School. No part of this case study
may be copied, reproduced or stored in a retrieval system or transmitted in any form
without permission from NDDU or the authors.

Case Study No. __

Series of 2016

CHRONIC KIDNEY DISEASE

SECONDARY TO HYPERTENSIVE
NEPHROSCLEROSIS

Jona Phie D. Montero

Master of Arts in Nursing
Notre Dame of Dadiangas University
General Santos City, Philippines
Montero, Jona Phie D.

ACKNOWLEDGEMENT

The graduate student would like to express her heartfelt gratitude to all people

who provided their unselfish assistance throughout the making of this study.

She extends her warm appreciation and gratitude to the following:

Marilou Villegas RN., MAN., Her Professor, for her encouragement and

support;

Her guardians, Rolando B. Montero, Jogie B. Montero and Rosita B. Montero,

who never failed to express their love by giving her moral, spiritual and emotional

supports;

Her parents, Johnny B. Montero and Espie D. Montero for their undying

support and encouragement;

Her sister Sharen Jill D. Montero, for the love, inspiration and encouragement;

Franklin E. Menor and Elizabeth S. Liba, her classmates and friends whom she

has established well and trusting relationship;

Mr. R, the respondent for sharing his health history and the details about his

disease,

And finally, the Almighty God, Who is the main source of life, the most special

gratitude is raised in prayer, for all the blessings and guidance He has given that led to the

success of this study.

To all of you, God Bless!

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CHRONIC KIDNEY DISEASE SECONDARY TO

HYPERTENSIVE NEPHROSCLEROSIS

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TABLE OF CONTENTS

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 CHRONIC KIDNEY DISEASE SECONDARY TO HYPERTENSIVE NEPHROSCLEROSIS

CHAPTER 1

Etiology, Incidence and Epidemiology

Chronic Kidney Disease (CKD) is defined as the presence of kidney damage,

manifested by abnormal albumin excretion or decreased kidney function, quantified by

measured or estimated glomerular filtration rate (GFR) that persists for more than three

months( National Kidney Foundation, 2006). In order to improve the understanding of

patients, families, healthcare workers, and the lay public, the National Kidney Foundation

Kidney Disease Outcomes Quality Initiative™ (NKF KDOQI™) uses the term kidney

rather than renal. The term CKD includes the continuum of kidney dysfunction from mild

kidney damage to kidney failure, and it also includes the term, end-stage renal disease

(ESRD) (Krol, 2011). To facilitate assessment of CKD severity and, the National Kidney

Foundation developed criteria, as part of its Kidney Disease Outcomes Quality Initiative

(NKF KDOQI™), stratify CKD patients as follows: Stage 1: normal eGFR ≥ 90 mL/min

per 1.73 m2 and persistent albuminuria; Stage 2: eGFR between 60 to 89 mL/min per

1.73 m2; Stage 3: eGFR between 30 to 59 mL/min per 1.73 m2; Stage 4: eGFR between

15 to 29 mL/min per 1.73 m2 and Stage 5: eGFR of < 15 mL/min per 1.73 m2 or end-

stage renal disease (Coresh et al, 2003).

Persons with CKD have significantly higher rates of morbidity, mortality,

hospitalizations, and healthcare utilization. The current estimate is that 26 million US

persons >20 y.o. have CKD. However, 15.2 % is the more recent CKD prevalence

estimate, based on 2003–2006 NHANES data of U.S. adults aged 20 y.o., a decrease

from the 15.9% cited in the NHANES data collected from 1999–2002 ( Krol 2011).

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In the past, chronic glomerulonephritis was the most common cause of chronic

renal failure. Today, diabetes mellitus and hypertension have taken center stage as the

main causes of ESRD, which together account for almost 60 percent of dialysis patients

(Manila Times, 2014). In 2004, 1,212,306 adult Filipinos have CKD (Philippine Society

of Nephrology). CKD is also associated with certain diseases such as: Anemia; mineral

and bond disorders, cardiovascular risk, dyslipedema and nutritional problems (Thomas

et al, 2009). The website of the National Kidney and Transplant Institute (NKTI) said

kidney diseases, especially End Stage Renal Disease (ESRD), are the 7th leading cause of

death in the country. One Filipino develops chronic renal failure every hour, or about 120

Filipinos per million people per year, (NKTI, 2014).

Objectives of the Study

This study aimed to present the case of Chronic Kidney Disease secondary

to Hypertensive Nephrosclerosis with complication of upper gastrointestinal bleeding

secondary to uremic gastropathy in relation to the learned concepts in Medical-Surgical

Nursing.

Specifically, this study sought to answer the following questions:

1. What is the comprehensive profile of the respondent?

2. What is the actual pathophysiology of the disease of the respondent?

3. What is the medical management of the respondent?

4. What are the diagnostic studies conducted to the client?

5. What are the medications prescribed by the physician of the respondent?

6. What is the comprehensive health history of the respondent in terms of:

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6.1. Present Health History; and

6.2. Past Health History?

7. What are the results of physical exams of respondent?

8. What is health status of the respondent in terms of Gordon’s Functional Health

Pattern?

Significance of the Study

The findings of this study are hoped to be of great significant to the following

target population:

CKD Diagnosed and at Risk Patients

For them to know the risk factors, signs and symptoms as well as the prevention

and management of the disease.

Health Sector

For them to identify the behavior and history of a patient with CKD in order for

them to develop a program appropriate for them.

Future Researcher

This study may help them as their basis for future researches.

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Definitions of Terms

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Chapter II
Review of Related Literature and Studies

Anatomy and Physiology

Function of the Urinary System:

The principal function of the urinary system is to maintain the volume and
composition of body fluids within normal limits. One aspect of this function is to rid the
body of waste products that accumulate as a result of cellular metabolism and because
of this, it is sometimes referred to as the excretory system.

Although the urinary system has a major role in excretion, other organs
contribute to the excretory function. The lungs in the respiratory system excrete some
waste products, such as carbon dioxide and water. The skin is another excretory organ
that rids the body of wastes through the sweat glands. The liver and intestines excrete
bile pigments that result from the destruction of hemoglobin. The major task of excretion

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still belongs to the urinary system. If it fails the other organs cannot take over and
compensate adequately.
The urinary system maintains an appropriate fluid volume by regulating the
amount of water that is excreted in the urine. Other aspects of its function include
regulating the concentrations of various electrolytes in the body fluids and maintaining
normal pH of the blood.
In addition to maintaining fluid homeostasis in the body, the urinary system
controls red blood cell production by secreting the hormone erythropoietin. The urinary
system also plays a role in maintaining normal blood pressure by secreting the enzyme
renin.

Components of the Urinary System:

The urinary system consists of the kidneys, ureters, urinary bladder, and urethra.
The kidneys form the urine and account for the other functions attributed to the urinary
system. The ureters carry the urine away from kidneys to the urinary bladder, which is a
temporary reservoir for the urine. The urethra is a tubular structure that carries the urine
from the urinary bladder to the outside.

KIDNEYS
The kidneys are the primary
organs of the urinary system.
The kidneys are the organs that
filter the blood, remove the
wastes, and excrete the wastes
in the urine. They are the organs
that perform the functions of the
urinary system. The other
components are accessory
structures to eliminate the urine
from the body.

The paired kidneys are

located between the twelfth thoracic and third lumbar vertebrae, one on each side of the

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vertebral column. The right kidney usually is slightly lower than the left because the liver
displaces it downward. The kidneys protected by the lower ribs, lie in shallow
depressions against the posterior abdominal wall and behind the parietal peritoneum.
This means they are retroperitoneal. Each kidney is held in place by connective tissue,
called renal fascia, and is surrounded by a thick layer of adipose tissue, called perirenal
fat, which helps to protect it. A tough, fibrous, connective tissue renal capsule closely
envelopes each kidney and provides support for the soft tissue that is inside.

In the adult, each kidney is approximately 3 cm thick, 6 cm wide and 12 cm long.

It is roughly bean-shaped with an indentation, called the hilum, on the medial side. The
hilum leads to a large cavity, called the renal sinus, within the kidney. The ureter and
renal vein leave the kidney, and the renal artery enters the kidney at the hilum.
The outer, reddish region, next to the capsule, is the renal cortex. This surrounds
a darker reddish-brown region called the renal medulla. The renal medulla consists of a
series of renal pyramids, which appear striated because they contain straight tubular
structures and blood vessels. The wide bases of the pyramids are adjacent to the cortex
and the pointed ends, called renal papillae, are directed toward the center of the kidney.
Portions of the renal cortex extend into the spaces between adjacent pyramids to form
renal columns. The cortex and medulla make up the parenchyma, or functional tissue, of
the kidney.
The central region of the kidney contains the renal pelvis, which is located in the
renal sinus and is continuous with the ureter. The renal pelvis is a large cavity that
collects the urine as it is produced. The periphery of the renal pelvis is interrupted by
cuplike projections called calyces. A minor calyx surrounds the renal papillae of each
pyramid and collects urine from that pyramid. Several minor calyces converge to form a
major calyx. From the major calyces the urine flows into the renal pelvis and from there
into the ureter.
Each kidney contains over a million functional units, called nephrons, in the
parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle and a
renal tubule. The renal corpuscle consists of a cluster of capillaries, called the
glomerulus, surrounded by a double-layered epithelial cup, called the glomerular
capsule. An afferent arteriole leads into the renal corpuscle and an efferent arteriole
leaves the renal corpuscle. Urine passes from the nephrons into collecting ducts then
into the minor calyces.

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The juxtaglomerular apparatus, which monitors blood pressure and secretes

renin, is formed from modified cells in the afferent arteriole and the ascending limb of the
nephron loop.

Parts of the Kidney:

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.

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

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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 re-absorbed in the medulla and
put back into 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.

Glomerulus and Bowman's Capsule - This is where ultra-filtration 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.

Proximal Convoluted Tubules - 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 re-absorbed 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 realize 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.

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URETERS

Each ureter is a small tube, about 25 cm long

that carries urine from the renal pelvis to the urinary
bladder. It descends from the renal pelvis, along the
posterior abdominal wall, behind the parietal
peritoneum, and enters the urinary bladder on the
posterior inferior surface.

The wall of the ureter consists of three layers.

The outer layer, the fibrous coat, is a supporting layer
of fibrous connective tissue. The middle layer, the
muscular coat, consists of inner circular and outer
longitudinal smooth muscle. The main function of this
layer is peristalsis to propel the urine. The inner
layer, the mucosa, is transitional epithelium that is continuous with the lining of the renal
pelvis and the urinary bladder. This layer secretes mucus which coats and protects the
surface of the cells.

URINARY BLADDER

The urinary bladder is a

temporary storage reservoir for
urine. It is located in the pelvic
cavity, posterior to the symphysis
pubis, and below the parietal
peritoneum. The size and shape
of the urinary bladder varies with
the amount of urine it contains
and with pressure it receives from
surrounding organs.

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The inner lining of the urinary bladder is a mucous membrane of transitional

epithelium that is continuous with that in the ureters. When the bladder is empty, the
mucosa has numerous folds called rugae. The rugae and transitional epithelium allow
the bladder to expand as it fills.

The second layer in the walls is the submucosa that supports the mucous
membrane. It is composed of connective tissue with elastic fibers.

The next layer is the muscularis, which is composed of smooth muscle. The
smooth muscle fibers are interwoven in all directions and collectively these are called the
detrusor muscle. Contraction of this muscle expels urine from the bladder. On the
superior surface, the outer layer of the bladder wall is parietal peritoneum. In all other
regions, the outer layer is fibrous connective tissue.

There is a triangular area, called the trigone, formed by three openings in the
floor of the urinary bladder. Two of the openings are from the ureters and form the base
of the trigone. Small flaps of mucosa cover these openings and act as valves that allow
urine to enter the bladder but prevent it from backing up from the bladder into the
ureters. The third opening, at the apex of the trigone, is the opening into the urethra. A
band of the detrusor muscle encircles this opening to form the internal urethral sphincter.

URETHRA

The final passageway for the flow of urine is

the urethra, a thin-walled tube that conveys urine
from the floor of the urinary bladder to the outside.
The opening to the outside is the external urethral
orifice. The mucosal lining of the urethra is
transitional epithelium. The wall also contains
smooth muscle fibers and is supported by
connective tissue.

The internal urethral sphincter surrounds the

beginning of the urethra, where it leaves the urinary

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bladder. This sphincter is smooth (involuntary) muscle. Another sphincter, the external
urethral sphincter, is skeletal (voluntary) muscle and encircles the urethra where it goes
through the pelvic floor. These two sphincters control the flow of urine through the
urethra.

In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The
external urethral orifice opens to the outside just anterior to the opening for the vagina.

In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and

transports both urine and semen. The first part, next to the urinary bladder, passes
through the prostate gland and is called the prostatic urethra. The second part, a short
region that penetrates the pelvic floor and enters the penis, is called the membranous
urethra. The third part, the spongy urethra, is the longest region. This portion of the
urethra extends the entire length of the penis, and the external urethral orifice opens to
the outside at the tip of the penis.

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UPPER GASTROINTESTINAL TRACT

Digestion is the process by which food is broken down into smaller pieces so that
the body can use them to build and nourish cells and to provide energy. Digestion
involves the mixing of food, its movement through the digestive tract (also known as the
alimentary canal), and the chemical breakdown of larger molecules into smaller
molecules. Every piece of food we eat has to be broken down into smaller nutrients that
the body can absorb, which is why it takes hours to fully digest food.
The digestive system is made up of the digestive tract. This consists of a long tube of
organs that runs from the mouth to the anus and includes the esophagus, stomach, small
intestine, and large intestine, together with the liver, gall bladder, and pancreas, which
produce important secretions for digestion that drain into the small intestine. The
digestive tract in an adult is about 30 feet long.

1. Mouth and Salivary Glands Digestion - begins in the mouth, where chemical and
mechanical digestion occurs. Saliva or spit, produced by the salivary glands (located
under the tongue and near the lower jaw), is released into the mouth. Saliva begins to
break down the food, moistening it and making it easier to swallow. A digestive enzyme
(called amylase) in the saliva begins to break down the carbohydrates (starches and
sugars). One of the most important functions of the mouth is chewing. Chewing allows
food to be mashed into a soft mass that is easier to swallow and digest later.

2. Esophagus - Once food is swallowed, it enters the esophagus, a muscular tube that is
about 10 inches long. The esophagus is located between the throat and the stomach.
Muscular wavelike contractions known as peristalsis push the food down through the
esophagus to the stomach. A muscular ring (called the cardiac sphincter) at the end of the

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esophagus allows food to enter the stomach, and, then, it squeezes shut to prevent food
and fluid from going back up the esophagus.

3. Stomach - a J-shaped organ that lies between the esophagus and the small intestine in
the upper abdomen. The stomach has 3 main functions: to store the swallowed food and
liquid; to mix up the food, liquid, and digestive juices produced by the stomach; and to
slowly empty its contents into the small intestine.

4. Small Intestine - Most digestion and absorption of food occurs in the small intestine.
The small intestine is a narrow, twisting tube that occupies most of the lower abdomen
between the stomach and the beginning of the large intestine. It extends about 20 feet in
length. The small intestine consists of 3 parts: the duodenum (the C-shaped part), the
jejunum (the coiled midsection), and the ileum (the last section). The small intestine has 2
important functions. First, the digestive process is completed here by enzymes and other
substances made by intestinal cells, the pancreas, and the liver. Glands in the intestine
walls secrete enzymes that breakdown starches and sugars. The pancreas secretes
enzymes into the small intestine that help breakdown carbohydrates, fats, and proteins.
The liver produces bile, which is stored in the gallbladder. Bile helps to make fat
molecules (which otherwise are not soluble in water) soluble, so they can be absorbed by
the body. Second, the small intestine absorbs the nutrients from the digestive process.
The inner wall of the small intestine is covered by millions of tiny fingerlike projections
called villi. The villi are covered with even tinier projections called microvilli. The
combination of villi and microvilli increase the surface area of the small intestine greatly,
allowing absorption of nutrients to occur. Undigested material travels next to the large
intestine.

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Pathophysiology (book based)

Chronic kidney disease (CKD)—or chronic renal failure (CRF), as it was

historically termed—is a term that encompasses all degrees of decreased renal function,
from damaged–at risk through mild, moderate, and severe chronic kidney failure.

Pathophysiology

There are many diseases that cause Chronic Kidney Disease; each has its own
pathophysiology. However, there are common mechanisms for disease progression.
Pathologic features include fibrosis, loss of renal cells, and infiltration of renal tissue by
monocytes and macrophages. Proteinuria, hypoxia, and extensive angiotensin II
production all contribute to the pathophysiology. In an attempt to maintain GFR, the
glomerular hyperfiltration; this results in endothelial injury. Proteinuria results from
increased glomerular permeability and increased capillary pressure. Hypoxia also
contributes to disease progression. Angiotensin II increases glomerular hypertension,
which further damages the kidney.

Predisposing Factors

 Diabetes, which is the most common risk factor for chronic kidney failure in the
United States
 Age 60 or older
 Kidney disease present at birth (congenital)
 Family history of kidney disease
 Autoimmune Disorder (Lupus erythematosus)
 Bladder outlet obstruction (BPH and Prostatitis)
 Race (Sickle cell disease)

Precipitating Factors

 Occupational Hazard (overexposure to toxins and to some medications¬)

 Sedentary Lifestyle (hypertension, atherosclerosis)
 Diet (High residue diet)

Clinical Manifestations
Laboratory Studies
Diagnosis/Differential Diagnosis
Treatment

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Chapter III
Research Method

Research Locale
Respondents of the Study
Sources of Data

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Chapter IV
Presentation and Assessment of Data

Comprehensive Patient Database

Pathophysiology (actual)
Medical / Surgical Management ( Actual )
Diagnostic Studies
Drug Studies
Present and Past Nursing Health History ( Comprehensive)
Physical Examination

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Gordon’s Functional Health Pattern

Functional Cue Cluster Inference Diagnostic Priority Rationale

Health Statement
Pattern

Problem List

NURSING DIAGNOSIS (PES format) PRIORITIZATION

NCP ( identify only 1 problem)

Nursing Desired Nursing Rationale Evaluation Intervention

Problem Outcome Interventions Modification
Subjective General
cues: Objectives:

Objective
cues: Specific
Objectives
Brief
Knowlede
Backgroung

Patient Outcomes and Continuity of Care

Prognosis
Discharge Plan

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REFERENCES (separate page) use APA FORMAT

Boaduo, N. A-P., Mensach, J. & Babitseng, S.M. (2009). Tracer Study as a Paradigm for
the Enhancement of Quality Course Programs Development in HEIs in South Africa.
Paper presented at the Educational Colloquium, University of the North-West,
Potchefstroom, South Africa, 20-21 August 2009. Retrieved June 2014 from
http://webreg.uzulu.ac.za:8090/itsquery/showQualEnrolment.jsp

Burnside Robert M.(2001) “E-learning Who Has the Goods?” The Technology

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Source, July/August 2001. Retrieved October 2014 from

http://ts.mivu.org/default.asp?show=article&id=1034.

Graduate School Bulletin (2013) Notre Dame of Marbel University

Manual of Operations (2011). Notre Dame of Marbel University

Schomburg, H. (2003) Handbook for Graduate Tracer Studies. Centre for Research on
Higher Education and Work, Kassel: University of Kassel.
Vol. 11, No. 3.

National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice
Recommendations for Anemia in Chronic Kidney Disease. Am.J.Kidney Dis.
2006;47:S11–S145.

Appendices
Documentation
Curriculum Vitae

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