CASE STUDY (CRITICAL CARE NURSING:

ELECTIVE II)
PREPARED BY:
A. CUEVAS
J. CHUA
A. MAMING

UTI

CKD
secondary to diabetes and hypertensive
Pleural effusion and ascites secondary to hypoalbumin secondary
to CKD/liver-
pathology
DM type II uncontrolled
Personal Data

Name: Pt. S
Gender: M
Age: 76 yrs old
Birthday: August 27, 1933
Birthplace: Panabo City
Nationality: Filipino
Address: 7091 Liceralde Subdivision, Panabo City
Religion: Jehovas Witnesses
Education Level: High School Graduate
Occupation: Farmer and Photographer
No. of Dependents and Siblings: Seven siblings
Marital Status: Married

Clinical Data

Chief Complaint: Body Malaise

Date of Admission: June 27, 2010
Admitting Diagnosis:
UTI

CKD secondary to diabetes and hypertensive

Pleural effusion and ascites secondary to hypoalbumin

secondary to CKD/liver-
pathology
DM type II uncontrolled

Ward: Sta. Rosa

Attending Physician: Dr. Maria Clara Teresa, M.D.
Date of Discharge:
Final Diagnosis: Chronic Kidney Disease (CKD) Secondary to
Diabetes & Hypertensive Nephropathy
Past
History

According to our patient, in year 1996 he experienced

gangrenous at the right leg which causes amputation of his right
big toe. He was diagnosed to have diabetes mellitus, twenty
years ago and diagnosed as hypertensive, ten years ago.

Present History

Eight days prior to admission, the patient had onset of body

malaise and numbness of lower extremities which resulted to
difficulty in walking, chills were noted and also colds and
dyspnea. Consultation was done and also laboratory tests which
had a result of decrease in K, which mange by giving Kalium
Dumule and Insulin injection.
Six days prior to admission there is a presence of symptoms of
CKD which he was admitted in Panabo Polymedic Hospital. There
were episodes of fever, chills, and constipation.

Definition of Diagnosis
Chronic Kidney Disease (CKD) Secondary to Diabetes &
Hypertensive Nephropathy
Pleural Effusion & Ascites Secondary to Hypoalbuminemia
Secondary to CKD/ Liver Pathology
Diabetes mellitus (DM) Type 2 Uncontrolled
Urinary Tract Infection
CHRONIC KIDNEY DISEASE (CKD)
CKD is a progressive, irreversible loss of kidney function that develops over days to
years. Aggressive management of hypertension and diabetes mellitus and avoidance of
nephrotoxic agents may slow progression of CKD; however loss of glomerular filtration
is irreversible and can lead to end-stage renal disease (ESDR).

CKD is a term that describes kidney damage or a decrease in glomerular filtration rate
for 3 or more months. Untreated CKD can result in end-stage renal disease (ESRD)
and necessitate renal replacement therapy.

Chronic renal failure represents progressive and irreversible destruction of kidney

structures. It results in loss of renal cells with progressive deterioration of glomerular
filtration, tubular reabsorptive capacity, and endocrine functions of the kidney.

o Chronic kidney disease(CKD), also known aschronic renal disease, is a progressive

loss of renal functionover a period of months or years. Chronic kidney disease is
identified by ablood testforcreatinine. Higher levels of creatinine indicate a falling
glomerular filtration rateand as a result a decreased capability of the kidneys to
excrete waste products.
DIABETES
DM is a group of metabolic disease characterized by
increased level of glucose in the blood (hyperglycemia)
resulting from defects in insulin secretion, insulin action, or
both. The major source of glucose is absorption of ingested
food in the gastrointestinal tract and formation of glucose by
the liver from food substances.

DM is a chronic disease of absolute or relative insulin

deficiency or resistance characterized by disturbances in
carbohydrate, protein, and fat metabolism.

DM is a chronic, progressive disease characterized by the

bodys inability to metabolized carbohydrates, fats, and
proteins, leading to hyperglycemia (high blood glucose level).
 DM is a disorder of carbohydrate, fat, and protein
metabolism brought about by impaired beta cell
synthesis or release of insulin, or the inability of
tissues to use glucose.
Type 1: results from loss of beta cell function
and absolute insulin deficiency.
Type 2: results from impaired ability of the
tissues to use insulin (insulin resistance)
accompanied by a relative lack of insulin or
impaired release of insulin in relation to blood
glucose levels.
HYPERTENSIVE
It is a persistently high blood pressure. In adults, this means a
systolic pressure that is equal to or greater than 140 mmHg & a
diastolic pressure that is equal to or greater than 90 mmHg.

Persistent elevation of the systolic blood pressure (SBP) at a level

of 140 mmHg or higher & diastolip blood pressure (DBP) at a level
of 90 mmHg or above.

A persistently high blood pressure. It is known as silent killer

bcause it can cause considerable damage to the blood vessels,
heart, brain, and kidneys before it causes pain or other noticeable
symptoms. This damages the kidney arterioles, causing them to
thicken, which narrow the lumen; because the blood supply to the
kidney is thereby reduced, the kidney secrete more renin, which
elevates the blood pressure even more.
NEPHROPATHY
Diabetic Nephropathy is the result of an alteration
in glomerular function. There is thickening of the
basement membranes of the glomerular
capillaries, leading to the development of
glomerular sclerosis. These changes in the
glomeruli are accompanied by a small urinary loss
of albumin.

Diabetic Nephropathy is the most common cause

of stage 5 chronic kidney disease, formerly known
as end-stage renal disease. Nephropathy involves
damage to and obliteration of the capillaries that
supply the glomeruli of the kidney.
 Any disease of the kidney. Nephrotic syndrome is a
condition characterized by proteinuria (protein in
urine) and hyperlipidemia (high blood levels of
cholesterol, phospholipids, and triglycerides).
Proteinuria is due to an increased permeability of the
filtration membrane, which permits proteins,
especially albumin, to escape from blood into urine.

4. Diabetic nephropathies is used to describe the

combination of lesions that often occur concurrently

in diabetic kidney. The most kidney lesions in diabetic
people are those that affect the glomeruli. It is the
leading cause of end-stage renal failure (ESRD).
PLEURAL EFFUSION
Pleural effusion is a collection of fluid in the
pleural space, is rarely a disease process; it is
usually secondary to other diseases. Normally,
the pleural space must contain only a small
amount of fluid which acts as a lubricant that
allows the pleural surfaces to move without
friction.

It is an abnormal collection of fluid or exudate in

the pleural cavity. The fluid maybe a transudate,
exudate, purulent drainage, chyle, or blood.
ASCITES
Accumulation of fluid in the peritoneal cavity
that results from the interaction of several
pthophysologic changes. Portal hypertension,
lowered plasma colloidal osmotic pressure, &
sodium retention all contribute to this condition.
Accumulation of serous fluid in the peritoneal
cavity.
Hypoalbuminemia
Hypoalbuminemia (low blood albumin level)
happens once liver production of albumin fails to
meet increased urinary losses.
DM TYPE 2
Type 2 DM range from mostly insulin resistance with relative insulin
deficiency to predominantly secretory defect with insulin resistance. It is
a nonketotic form of DM and there is no autoimmune destruction of the
pancreatic islet b cells.

Type 2 DM is previously called adult-onset diabetes mellitus, is a disorder

involving both genetic and environmental factors. This type of DM has
limited beta-cell response to hyperglycemia. As the beta-cells are exposed
to high levels of glucose, they become progressively less efficient.

Type 2 DM has 2 main problems and these are insulin resistance and
impaired insulin secretion. Insulin resistance refers to decreased tissue
sensitivity to insulin. Normally, insulin binds to special receptors on cell
surfaces and initiates a series of reactions involved in glucose
metabolism. But, in type 2 DM, these intracellular reactions are
diminished, making insulin less effective at stimulating glucose uptake
by the tissues and at regulating glucose release by the liver.
URINARY TRACT INFECTION (UTI)

Used to describe either an infection of a part of the

urinary system of the presence of large numbers of
microbes in urine. Symptoms include painful or
burning urination, urgent and frequent urination,
low back pain, and bed wetting.

UTIs are caused by pathogenic microorganisms in

the urinary tract. They are generally classified as
infections involving the upper and lower urinary
tract and further classified as uncomplicated or
complicated, depending on other patient-related
conditions.
NURSING DIAGNOSIS
Excess fluid volume related to compromised
regulatory mechanism.
Fluid volume excess or hypervolemia occurs from
an increase in total body sodium content and an
increase in total body water. This fluid excess
usually results from compromised regulatory
mechanisms for sodium and water as seen in
CHF, kidney failure, and liver failure.
INTERVENTIONS
Assess for presence of edema by palpating over tibia, ankles,
feet, and sacrum.
Pitting edema is manifested by a depression that remains after
ones finer is pressed over an edematous area and then removed.
Monitor daily weight of the patient.

Any change in weight is indicative of increase extracellular

fluid volume.
Monitor VS of the patient.

Tachycardia and increased blood pressure are seen in early

stages. Elderly patients have reduced response to
catecholamines, thus their response to fluid overload may be
blunted, with less rise in heart rate.
Auscultate for a 3rd sound.

S3 sound is an early sign of pulmonary congestion.

 Monitor for distended neck veins and ascites.
Distended neck veins mean increase pressure in the jugular veins
brought about by increased circulating fluid.

Monitor abdominal girth daily.

Monitor input an output
Although overall fluid intake may be adequate, shifting of fluid
out of the intravascular to extravascular spaces may result in
dehydration.
Evaluate urine output in response to diuretic therapy.

Focus on monitoring the response to the diuretics, rather than the

actual amount voided. Fluid volume excess in the abdomen may
interfere with the absorption of oral diuretic medications.
Check urinary catheter for presence of urine.

Treatment focuses on diuresis of excess fluid

 Fluid & electrolyte imbalance related to excessive
urination

Excessive urination coupled by impaired

glomerular filtration rate can affect reabsorption
of sodium in the distal renal tubule, excretion of
creatinine in the urine and wastage of calcium
which will result to muscular spasms if not
corrected.
INTERVENTIONS
Assess capillary refill time of the patient regularly including the
mucus membrane and skin turgor.
These are indicators of dehydration, adequacy of circulating
volume.

Monitor intake and output

Provide ongoing estimation of volume replacement needs, kidney

function, & effectiveness of therapy.

Instruct patient to increase oral fluid intake to at least 2.5 L/day

or above depending on the amount determined by the health care

provider.
Maintains hydration and circulatory volume.
Promote comfortable environment: cover patient with light sheets.

Avoid overheating which could promote further fluid loss.

 Continue to administer fluids
Type and amount of fluids depends on the degree of deficit
and individual patient response

Instruct patient to take high-water content foods like

watermelon and soup if not contraindicated.

Replace fluid loss in the body due to excessive urination

Administer medications as ordered.

Monitor serum electrolytes and urine osmolarity

Elevated hemoglobin and elevated blood urea nitrogen

suggest fluid deficit. Urine-specific gravity is likewise
MEDICAL MANAGEMENT
ACTUAL
CHEST X-RAY
Result: The lungs show no definite recent
evidence of active pulmonary infiltrates.
-Heart is magnified.

-Aortic knob is calcified.

-Left costrophenic sulcu is blusted. Diaphragm

and right costrophenic sulcus are intact.
-Old healed fracture is appreciated in the 5 th
right posterior rib.
-The rest of the included structure are
unremarkable.
 Interpretation:
Left Pleural Effusion

- may compress the lungs and cause collapse of the alveoli;

impairing gas exchange and result to respiratory distress

Atherosclerotic Aorta

- the thrombus that formed in the intimal layer of the

aorta may dislodge and become an emboli and travels to
the pulmonary circulation, causing pulmonary embolism
and later on would result to CHF, or travel to the
systemic circulation obstructing blood flow to the
peripheries causing hypotension or worse tissue necrosis.

 Old healed fracture left 5th posterior rib
-may become brittle as client aged. It might break
again and cause injury to the underlying organs.
COMPLETE BLOOD COUNT (CBC)
Result:
Hemoglobin 121
Erythrocyte 3.88
Leukocytes 12.1
Neutrophils 0.70
Lymphocytes 0.17
Monocytes 0.08
Hematocrit 0.37
Platelet 322
INTERPRETATION
Decreased hemoglobin and erythrocyte
-indicates anemia. If RBC is decreased, the hemoglobin decreases also. This means
that exchange of gases between the alveoli, and the capillary beds are affected,
and there will be less oxygenated blood circulating the body, and hypoxia results.
This is caused by impaired production of erythropoietin by the kidney.
Eythropoietin stimulates the bone marrow to produce blood products especially
RBC.

Increased Leukocytes

-Increase in number indicates infection or damage caused by bacteria, viruses, etc.

The patient is diagnosed to have UTI, specifically cystitis.

Increased Neutrophils

Also indicates infection. Neutrophils are avid phagocytes at sites of acute infection.

o Decreased Lymphocytes

-Patient is prone to immunosupression since his lymphocytes are small in number.

Lymphocytes play an important role in immune response (B and T lymphocytes).

Increased Monocytes
-Indicates chronic infection. Monocytes are active phagocytes that become
macrophages in the tissues. They are called the long-term clean-up team.
 Decreased Hematocrit
-Hemodilution or there is decreased concentration
of RBC in the blood. Plasma volume is increased
because of fluid shifting.

High Platelet

-Risk for coagulation/clotting, and may lead to

arteriosclerosis due to thrombus formation.

 Urine Culture and Sensitivity

Multiple Growth of Microorganisms; Result proves infection of the urinary
tract (cystitis).
o Serum Electrolytes

Results:
Creatinine 389.0
Normal: 53-115
Interpretation:
Increased creatinine levels in the blood suggest diseases or conditions that

affect kidney function.

Creatinine reflects glomeruli filtration rate.

Some signsand
symptomsof kidney dysfunction include:

Fatigue, lack of concentration, poor appetite, or trouble sleeping

Swelling or puffiness, particularly around the eyes or in the face, wrists,

abdomen, thighs or ankles

Urine that is foamy, bloody, or coffee-colored

A decrease in the amount of urine

Problems urinating, such as a burning feeling or abnormal discharge

during urination, or a change in the frequency of urination, especially at

night
Mid-back pain (flank), below the ribs, near where the kidneys are located
URINALYSIS
Result:
Color Yellow
Appearance Cloudy
Reaction 6.0
Specific Gravity 1.00
Chemical
Characteristics Alb-trace Sugar +++
Pus Cells 20-30
RBC 1-2
Interpretation:
Urine is not concentrated since color is not dark. Cloudy urine indicates
presence of WBC, bacteria, pus, contaminants, or prostatic fluid.
Glycosuria indicates high blood glucose levels and maybe indicative of
uncontrolled DM.
Hematuria can be caused by irritation or injury to endothelial wall of the
ureters
Proteinuria indicates kidney damage.
There is an increased pus cells which means infection is present.
ABG TEST
Result:
Ph 7.37
PCO2 67 (acidosis)
PO2 83
HC03 15 (acidosis)
o2 sat 96%

Interpretation: Fully Compensated Metabolic Acidosis

A high PaCO2(respiratory acidosis) indicates underventilation.

Carbon dioxideis produced constantly as the body burns energy, and this CO 2will
accumulate rapidly if the lungs do not adequately dispel it throughalveolar
ventilation. Alveolar hypoventilation thus leads to an increasedPaCO2(called
hypercapnia). The increase inPaCO2in turn decreases the HCO3/PaCO2ratio and
decreases pH.
-A low HCO2 indicates metabolic acidosis whichis a condition that occurs when
the body produces too much acid or when thekidneysare not removing enough
acid from the body.
 Lipoprotein Profile with Glucose and Uric Acid
Result:
HDL 0.40
Glucose 6.7
Interpretation:
There is very little high density lipoprotein or
good cholesterol which implies that there is lesser
chance for the remaining HDL to remove more
cholesterol from atheromas within the
arterisand transport it back to the liver for
excretion or re-utilization.
POSSIBLE
Uric Acid Test
The patient has been complaining of pain in the
pelvic area. Since he has CKD, his kidneys might
have broken down purine (protein) rather very
fast causing accumulation to the joints. It has to
be checked to know if the patient is suffering
from gout, Some patients with high levels of uric
acid have a disease calledgout, which is an
inherited disorder that affects purine breakdown.
Patients with gout suffer from joint pain, most
often in their toes but in other joints as well.
MANAGEMENT (THERAPEUTICS)
ORDER:
Venoclysis of PNSS1L to run at KVO rate.
R: NSS is a solution of common salt in distilled water, of strength of
0.9%. It is called normal saline because the percentage of salt
resembles that of the crystalloids in the blood plasma. It is an
isotonic solution. It is less irritating for the body cells. It is used to
patients with salt and water deprivation. KVO rate is ordered for
prophylactic access.
I & O q shift and VS q 4
R: This measures how much fluids are taken and how much has
been excreted. This also indicates any problem in the kidneys.
Vital signs are done every 4 hours to monitor the clients well
being such as temperature which is indicative of hyperthermia.
Calibrated diabetic diet
R: Diet for diabetic patients must be accurately weighed or gauged.
Too many carbohydrates mean too much glucose; too much protein
and fats may overwork the liver and kidneys.
 Increase oral fluid intake
R:To minimize formation of crystals in the urine.
Lipid profile, CBC, serum uric acid, KOH and urine culture
R: These laboratory tests measures the body chemistry such
lipoproteins, blood products, nitrogenous wastes, and presence of
infection in the urinary system.
Doppler scan the left extremity
R:To determine adequate blood flow in the extremities and to rule out
any obstruction.
Weighing once a day
R:To monitor any weight gain due to edema or increased extra-cellular
fluid.
Nebulization q 6 with Berodual
R: Berodual is a bronchodilating and anticholinergic agent which gives
of parasympatholytic effects. It relieves bronchospasms.
IVF rate to 60 cc/hr
R: To combat dehydration.
Moderate high back rest
R: Promotes thoracic expansion and facilities breathing.
Abdominal girth measurement
R: Measures extent of ascites
DRUG STUDY
Prednisone
Domperidone
Metroprolol
Calcium Carbonate
Imdur
THANK YOU

*MA. C