Case

Presentation
Chronic Renal failure
Personal Data
• Name: MCVM
• Age: 15 y/o
• Birthday: September 26, 1994
• Place of Birth: Manila
• Address: Paranaque
• Sex: Female
• Religion: Roman Catholic
• Nationality: Filipino
• Date of admission: April 19, 2010
• Admitting Impression: Chronic renal failure
secondary to neurogenic bladder secondary to spina
bifida.
History of Present Illness
MCVM was apparently well until 36 hours PTA. She had
headache described as throbbing located at fronto temporal
area with the severity of 7/10. No consult was done nor
medication taken until 30 hours PTA, patient had seizure
described as upward rolling of eyeball, stiffening of
extremities and cyanosis lasting for 30 seconds. Patient was
then rushed to Taguig Pateros District Hospital but patient
opted to transfer to another hospital due to poor service. 28
hours PTA, she had another episode of seizure with the same
characteristics hence consult Makati Medical Center when
CBC was one and revealed anemia. BUN crea was done
which showed marked increase about 4x higher than the
normal. PT, PTT, Potassium and Phosphorus are in normal
range. Patient was advised admission but due to no available
room patient noted to transfer to our institution and was
subsequently admitted.
Medical History
MCVM is born termed to 24 y/o G1P0 via NSD
at Paranaque Medical Center with no known feto-
maternal complication with no know maternal
complication. Patient is on breastfed until 4th months
and was shifted thereafter. She was started on solid
foods at 6th month of age.
No known allergies to drugs and foods. Patient
MCVM is fully immunized but the father cant recall
the date of her immunization.
She had her menarch when she was 10 y/o and
regular menstruation.
She had 2 previous hospitalizations.
Her first hospitalization was last 2005
when she 11 y/o. Patient was diagnosed
with spina bifida since birth, had s/p
correction and s/p spinal traction at San
Martin de porres Hospital.
Since then patient had urinary and
bowel incontinence with no maintenance
medications. On 2007-2009 she had
recurrent UTI and admitted to Asian
Hospital last 2007
Family History

No known heredofamilial disease

except asthma on paternal side.
Psychosocial History
MCVM is a 3rd year high school student
from Montessori Paranaque and tells us of
having many friends and good social
network. Hobbies include going out and
reading books. Her considered problems are
school works such as projects and
assignments and copes up with stress by
sleeping and playing.
Of her parents she is more attached to her
father because her parents are separated and
she considers her father as a support person.
ACTIVITIES OF
DAILY LIVING
 BEFORE DURING INTERPRETATIO
HOSPITALIZATIO HOSPITALIZATIO N
N N
FLUIDS C.M. was on NPO then was
&
C.M. eats three
shifted to a low phosphorus
NUTRITION times a day diet with a dietary
(breakfast, lunch, prescription of a total of
1800 calories (protein 70
dinner). She calories, fat 690 calories,
prefers to eat fried carbohydrates 1040
calories); she hasn’t drunk
food (e.g. chicken, any liquid despite her
pork, etc.) along relatives’ urgings, but on 4-
22-10 she drank 210 cc of
with one cup of
water; on IVF (PNSS 1L x
rice. She drinks 2-3 12 hours) then shifted to
glasses of Coke heplock; has had blood
transfusion (2 packs RBC
during meals. type O Rh (+))
Limited fluid intake to
1liter per day
A low phosphorus diet was
ordered for maintaining a
normal level of calcium in
the blood, since a high level
of phosphorus in the blood
could cause loss of calcium,
which is important in bone
formation; her refusal of
drinking anything was
caused by a feeling of
fullness in the bladder; IVF
was for maintaining
electrolyte balance and
renewal of fluids; heplock
is for IV medications;
blood transfusion was for a
low hemoglobin count
To prevent fluid overload
due to renal failure
 BEFORE DURING INTERPRETATIO
HOSPITALIZATION HOSPITALIZATION N
BOWEL
& C.M. wears a C.M. has had no Her negative bowel
ELIMINATION
diaper everyday bowel movement movement must be
since her admission, due to her limited
and everytime she and constantly activities, and pain
goes to school. complains of pain in in the area; her
She consumes 5-6 the anal area; still small amount of
diapers a day with undergoing urine output was
regular bowel hemodialysis, she has because of her
very little urine hemodialysis; the
movement (one to output (100-200 cc a use of underpads is
two times a day). day). Instead of using for comfort and an
diapers, she was easier way to
instructed by the measure the output.
doctor to use
underpads.
 BEFORE DURING INTERPRETATIO
HOSPITALIZATIO HOSPITALIZATIO N
N N
ACTIVITIES
C.M. goes to Regis Due to her
&
EXERCISE Grace Montessori in
complain of pain
The pain
Taguig. She travels by
jeepney, leaving the in the anal area, makes it
house at around 6:30 she stays at bed
am and goes home at
most of the time.
difficult
around 4:00 pm.
During school hours, She has limited for her to
she stays with her activities, and
friends. To pass the
spends most of
move
time when at home,
she reads books and the time resting around.
surfs the web. She also on her bed and
talks with her friends
via cellphone. During
watching TV.
weekends and special
occasions, she goes
malling with her
family.
 BEFORE DURING ANALYSIS
HOSPITALIZATION HOSPITALIZATION

REST She sleeps at She sleeps longer She has a

AND around 8:00 PM during her longer rest
confinement and period but due
SLEEP and wakes up at
sleeps at around to frequent
around 4:30 AM 9:00 PM and nurse and
to go to school. wakes up around doctor visits,
During 9:00 AM. her sleep is
weekends she However, due to disturbed and
sleeps at around the nursing care sometimes
rendered, her sleep feeling of in
9:00 PM and is sometimes pain and
wakes up at disturbed with irritated.
around 8:00 feelings of pain
AM. and irritation.
 BEFORE DURING ANALYSIS
HOSPITALIZATION HOSPITALIZATIO
N

ORAL She brushes her She brushes her She can only do
AND teeth every after teeth at night partial bath
HYGIENE
meals. She takes before going to because she
sleep with her complains of
a bath two to grandmother’s difficulty when
three times a day. help. Sometimes, moving around.
she took full bath Satisfaction of
but mostly partial hygienic needs
bath. And also is achieved
perineal care had dependent on
done by relative or the help of
staff nurse at least others.
once a day.
Physical Assessment
IX. DISEASE
ENTITY
The body takes nutrients from food
and converts them to energy. After
the body has taken the food that it
needs, waste products are left
behind in the bowel and in the
blood. 

The urinary system keeps the

chemicals and water in balance by
removing a type of waste called
urea from the blood. Urea is
produced when proteins, found in
meat products, are broken down in
the body.
• Two kidneys - a pair of purplish-brown organs located below the ribs
toward the middle of the back. Their function is to:

– Remove liquid waste from the blood in the form of urine.

– Keep a stable balance of salts and other substances in the blood.

– Produce erythropoietin, a hormone that aids the formation of red blood

cells.

• The kidneys remove urea from the blood through tiny filtering units called
nephrons. Each nephron consists of a ball formed of small blood
capillaries, called a glomerulus and a small tube called a renal tubule. Urea,
together with water and other waste substances, forms the urine as it passes
through the nephrons and down the renal tubules of the kidney.
• Two ureters - narrow tubes that carry urine from the kidneys to the bladder. 
Muscles in the ureter walls continually tighten and relax forcing urine downward,
away from the kidneys. If urine backs up, or is allowed to stand still, a kidney
infection can develop. About every 10 to 15 seconds, small amounts of urine are
emptied into the bladder from the ureters.

• Bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held

in place by ligaments that are attached to other organs and the pelvic bones. The
bladder's walls relax and expand to store urine and contract and flatten to empty
urine through the urethra. 

• Two sphincter muscles - circular muscles that help keep urine from leaking by
closing tightly like a rubber band around the opening of the bladder.

• Nerves in the bladder - alert a person when it is time to urinate, or empty the

bladder.

• Urethra - the tube that allows urine to pass outside the body. The brain signals the
bladder muscles to tighten, which squeezes urine out of the bladder. At the same
time, the brain signals the sphincter muscles to relax to let urine exit the bladder
through the urethra. When all the signals occur in the correct order, normal
urination occurs.
 Chronic Kidney Disease
• Chronic kidney disease occurs when one suffers from gradual and usually permanent loss of
kidney function over time. This happens gradually, usually months to years.
• With loss of kidney function, there is an accumulation of water; waste; and toxic substances,
in the body, that are normally excreted by the kidney. Loss of kidney function also causes
other problems such as anemia, high blood pressure, acidosis (excessive acidity of body
fluids), disorders of cholesterol and fatty acids, and bone disease
•
STAGES OF CKD

GFR*
Stage Description
mL/min/1.73m2
Slight kidney damage with
1 More than 90
normal or increased filtration
Mild decrease in kidney
2 60-89
function
Moderate decrease in kidney
3 30-59
function
Severe decrease in kidney
4 15-29
function
5 Kidney failure Less than 15
• 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)

•  At this advanced stage of kidney disease the kidneys have lost nearly all
their ability to do their job effectively, and eventually dialysis or a kidney
transplant is needed to live.

• Because the kidneys are no longer able to remove waste and fluids from
the body, toxins build up in the blood, causing an overall ill feeling.
Kidneys also have other functions they are no longer able to perform such
as regulating blood pressure, producing the hormone that helps make red
blood cells and activating vitamin D for healthy bones.
PATHOPHYSIOLOG
Y
 TREATMENT
and
MANAGEMENT
Name, Class, Dose, Mechanism of Indication Contraindication Side effects Nursing
Route,Frequen action responsibilitie
cy s

Calcium Decrease total To treat Hyper- Constipation, -Give antacid

carbonate acid load of GI flatulence, 1-3 hours after
Class: antacid tract. Increase
hyper- calcemia, meals
1tab p.o OD phosphate- hyper- diarrhea,
esophageal -encourage
mia for calciuria, hyper-
sphincter tone, client to drink
calcemia,
strengthens client with bone alkalosis,
at least 2oz. of
gastric renal tumors, water to ensure
mucosal renal that the drug
barrier and disorders. severe renal dysfunction, reaches the
reduce pepsin failure, gastric stomach
activity by parenteral hyper- -warn client to
elevating calcium secretion, avoid taking
gastric pH. acid rebound antacids with
therapy milk or foods
rich in vitamin
D
-Do not
administer oral
drugs within 1-
2 hour of
antacid
administration
 Diphen- Decrease Used in Acute Drowsiness, -inform client
that one of the
hydramine allergic symptoma asthmatic dizziness, side effects of
(benadryl) response by attacks , fatigue,
Class:
antagonizing
tic relief severe liver nausea,
the drug is
drowsiness
antihistamine
35mg IV Q8 the effect of of allergic disease, vomiting, -encourage
histamine conditions lower urinary client to avoid
performing
for H1 such as respiratory retention, activities alone
receptor site urticaria disease, constipation, when
in blood MAOI blurred drowsiness
vessels, GI,
and therapy, vision, dry occur
respiratory pruritic narrow mouth and
-provide safe
environment for
system skin angle throat, the client(e.g
disorders glaucoma, hypotension putting siderails
up)
stenosing
peptic ulcer
Paracetamol
Class: analgesic,
Decreases Treatment Hyper- Drowsiness, -Give with
fever by nausea, food or
antipyretic
inhibiting the of fever sensitivity,
500mg/tab 1tab vomiting, milk to
p.o prn effects of in- abdominal decrease
pyrogens on tolerance pain, hepa- gastric
the
hypothalamic to totoxicity symptoms
heat tartazine, - Give 30
regulating alcohol, mins.
centers and Before or 2
by a table hours after
hypothalamic sugar, meals
action leading saccharin
to sweating
and
vasodilation.
Hemodialysis
is the most common method used to
treat advanced and permanent kidney
failure.
• In hemodialysis, your blood is allowed
to flow, a few ounces at a time, through
a special filter that removes wastes and
extra fluids. The clean blood is then
returned to your body. Removing the
harmful wastes and extra salt and fluids
helps control your blood pressure and
keep the proper balance of chemicals
like potassium and sodium in your body.
NURSING CARE PLA
N