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INTRODUCTION

The kidneys are a pair of small (about the size of your fist-sized,) bean-shaped organs that lie on either side of your the spine located at just below your the lowest ribs. They filter by-products and toxins from your the blood and preserve the balance of bodily fluids and electrolytes.

The kidneys excrete these compounds with water to make urine. They also eliminate excess body water while reabsorbing useful chemicals and allowing waste to pass freely into the bladder as urine. They allow a person to consume a variety of foods, drugs, vitamins and nutritional supplements, additives, and excess fluids without worry that toxic by-products will build up to harmful levels. The kidneys regulate the amount of various substances in the blood and the amount of water in the body. Blood circulates through the kidneys for filtration.

As the first step in filtration, the blood passes through the glomeruli, complex structures composed of tiny blood vessels entwined together. Substances present in the blood are selectively filtered across the outer linings of the tiny blood vessels and excreted with water as urine or reabsorbed into tube-like structures (tubules) for further filtration. The tubules continue filtering blood until all appropriate substances are reabsorbed into the blood and all the waste products are excreted. Once urine leaves the kidney, it travels through long, thin tubular ureters to the bladder and out the urethra during urination. The kidneys also help regulate blood pressure and secrete hormones that contribute to red blood cell production. Kidney failure occurs when the kidneys partly or completely lose their ability to filter water and waste from the blood.

The build up of toxic substances normally removed from the body by the kidneys can cause dangerous health problems. Acute kidney failure (also referred to as renal failure) can happen rapidly. Mild kidney dysfunction is often called renal insufficiency. Acute kidney failure occurs in about 5% of people who are hospitalized for any reason. It is even more common in those receiving intensive care. Chronic kidney failure results when a disease slowly destroys the kidneys. Destruction occurs over many years, usually with no symptoms until the late stage of kidney failure. Progression may be so gradual that symptoms may not occur until kidney function is less than one-tenth of normal. Causes of acute kidney failure (also called acute kidney injury [AKI]) fall into one of the following categories:

Prerenal: Problems affecting the flow of blood before it reaches the kidneys Postrenal: Problems affecting the movement of urine out of the kidneys Renal: Problems with the kidney itself that prevent proper filtration of blood or production of urine According to the Department of Health for the year 2001 - 2006, kidney problems is rated number 10 that is causing mortality and morbidity in the country alone. Statistically, worldwide, there are cases of kidney problems noted but were not quite considered to very life threatening because of advance technologies that is being introduced to the market. II. BIOGRAPHICAL DATA Name of Patient: Patient R Sex: Male Age: 37 years old Civil Status: Married Religion: Roman Catholic Birthday: October 14, 1971 Birthplace: Tublay, Benguet Nationality: Filipino Address: Purok 8, Upper Pinget, Baguio City CHIEF COMPLAINT The patient entered the emergency room with a chief complaint of difficulty in breathing and chest pains. PAST MEDICAL HISTORY The patient is a known hypertensive and was diagnosed to have Chronic Kidney Disease since January, 2012. He was admitted twice at Baguio General Hospital due to the problem. He was discharged, given some medications but cannot recall the names, and did not comply to the medicines that were given and there were no follow up and consultations done. There were no known allergies to food and drugs. Family History: There are no family history of Bronchial Asthma, Kidney disease, Cerebrovascular disease, Coronary Artery Disease, Diabetes Mellitus and any seizure disorder. But according to him, they have a familial history of Hypertension. Social and Environmental History: According to the patient, they live in a noncongested neighborhood with his family. There are no family members or neighbors who have the same condition as his. He works as a jeepney driver. His diet would consist of meat, vegetables and he claims that he avoids salty foods. He states that he is not a smoker, but he used to drink alcoholic beverages three times a week. But according to him, he quitted 5 years ago.

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REVIEW OF SYSTEMS General: () weakness, () fatigue, () fever, () chills, () night sweats, () diaphoresis Skin: (+) pallor, (+) jaundice, () Cyanosis, () pigmentation, () rashes, () hives HEENT Head: () headache, () dizziness, () head injury Eyes: () blurred vision, pain, diplopia, visual dysfunctions, dryness, redness, tearing Ears: () tinnitus, deafness, pain, discharge Nose: () lacerations, epistaxis, discharge Mouth and Throat: () dryness, soreness, hoarseness of voice, cyanosis, change in tone in voice, decreased gustatory Neck: () lumps, pain Respiratory: () dyspnea, cough, hemoptysis, asthma Cardiology: () palpitation, chest discomfort, edema, nape pain, orthopnea, dyspnea, undue fatigue, paroxysmal nocturnal dypnea, cyanosis, syncope, (+) hypertension Gastrointestinal: () nausea, vomiting, dysphagia, hematemesis, indigestion, melena, hematochesia, heartburn, abdominal distention, loss of appetite, diarrhea, abdominal pain, jaundice, constipation, change in bowel habits Renal and Urinary: (+) oliguria, () frequency, polyuria, nocturia, dysuria, hematuria, anuria, retention, incontinence Peripheral and Vascular: (+) edema, () leg cramps, ulcers, intermittent claudication Musculoskeletal: () muscle and joint pains, cramps, weakness, stiffness, history of trauma, limited of movement, backache Hematological: () anemia, excessive bleeding, easy bruising Endocrine and Metabolic: () heat and cold intolerance, weight change, excessive sweating, polydypsia, polyphagia, polyuria Neurologic: () syncope, seizure, tremors, headache, weakness, head trauma, sleep disorder, coordination problems

Psychiatric and Emotional: () anxiety, depression, loss of control/ violence, nervousness, memory change, substance abuse V. CAUSE OF PRESENT ILLNESS The patient was apparently well, until 1 week prior to admission, the patient noted one episode of hematuria which was precipitated by straining while trying to defecate. According to him, he had an episode of fever although it was undocumented. There were no associated symptoms such as dysuria, oliguria and abdominal pain noted. No consultation was done and no medications were taken. Three days prior to admission, the patient had intermittent chest pains which was not precipitated by activity. The characteristic of pain was not severe and non radiating, and it was only localized to the chest area. According to him, the pain was tolerable and spontaneously resolved. No other associated symptoms such as palpitations, dyspnea, headache, nausea and vomiting, fever and abdominal pain noted. A few hours prior to admission, the patient was awakened by a sudden episode of difficulty of breathing. There were no associated symptoms such as chest heaviness noted. There were no cough and fever, hence prompted the admission. Initial Diagnosis: ACUTE RENAL FAILURE ON TOP OF CHRONIC KIDNEY DISEASE STAGE 5 SECONDARY TO HYPERTENSION NEPHROSCLEROSIS. HYPERTENSION II C ANEMIA SECONDARY TO PULMONARY CONGESTION SECONDARY TO ACID RELATED DISORDERS Final Diagnosis: ACUTE RENAL FAILURE ON TOP OF CHRONIC KIDNEY DISEASE STAGE 5 SECONDARY TO NYPERTENSIVE NEPHROSCLEROSIS Attending Physicians: Dr. George J. Pangwi and Dr. Viviene Untalan

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PATHOPHYSIOLOGY A. Schematic Diagram for Acute Renal Failure

Renal Cell anaerobic metabolism Tubular Necrosis Decreased ATP, Increased Acidosis

Tubular cells swell, necrose, BM altered Increased Cellular Calcium

RBC and cellular casts

Renal Cell Injury:

Altered tubular permeability:
Tubular obstruction

Increased Bowmans capsule hydrostatic pressure

Decreased reabsorption of sodium Decreased concentration filtrate Back leak tubular filtrate Decreased tubular filtrate

Decreased in Glomerular Filtration Rate (GFR)

Oliguria Decreased excretion of urea (elevated BUN) Decreased creatinine clearance (elevated Cr) Urine sodium = plasma sodium Isosthenuria

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LIST OF IDENTIFIED PROBLEMS PRIORITIZATION NURSING CARE PLAN