Case analysis:
CHRONIC KIDNEY DISEASE
A Case Study on the Concept of Fluids and Electrolytes
CHRONIC KIDNEY DISEASE-ESRD
Patient Marcos, 55-year-old male,
who stands 5 feet 8 inches and weighs 90 kg has
been rushed to the emergency department who
manifested deep, rapid, shallow breathing, mental
delirium and confused. Upon inspection, the
patient hair is coarse and blowsy. Eyes are
swollen and puffy. Nasal flaring is very evident.
Patient’s respiratory rate is 39cpm. As you go
down, you can see that the patients entire face
and body is having uremic frost. Cardiac rate is
111bpm. Upon lung auscultation, rales and
crackles was also heard. The patient’s nail beds
and palms are very pale. Pulse oximeter reads
89% saturation.
Patient Marcos, 55 yrs. old with
uremic frost
Abdominal girth is 48 inches. While doing your assessment the wife suddenly
cut you off by saying “Nagtaka ako dahil bigla na lang sya namanas. Ayaw niyang
humaga dahil nakakahingal daw. Ang kanyang singsing masikip na. Ang kanyang
medyas at sapatos hindi na magkasya sa kanya. Hindi din kami nakapag dialysis
na dapat dalawang beses sa isa lingo sa kadahilanang ako ay may Covid. 6
months ago nag umpisa ang kanyang dialysis at nasa kaliwang braso nya ang
kanyang AVF at diyan dinadaan pag diandialysis sya. Mamamatay na ba siya sir?”
“Ipapacheck po muna natin kay dok mam ha, at ichicheck ko din sya”. Salamat sa
observation mo maam. Ino-note ko lang lahat.”
Upon further assessment, you can see the presence of bipedal edema- grade 4+. The
daughter of the patient arrived and said “ang bilis nyang mapagod at hindi nya
kayang maglakad
ng matagal at madali lang sya hingalin kaya nag request ako ng wheelchair
kanina.” Vital signs checked with of BP 180/100mmHg, PR 108bpm, 39cpm,
Temperature 37.5 degree Celsius and with GFR 15ml/min was obtained by Doctor
Gow. NVS was also monitored (11/15) and CBG 190mg/dL.
While waiting for the physician, the nurse tried to interview the patient, but with
vague responses. The patient cannot talk well and is incomprehensible, restless,
and agitated- he did not even recognize his daughter. His wife said that one
month prior to admission, the patient had difficulty sleeping and had started
to use 2 pillows to support his back when lying down because he cannot
breathe properly. Nevertheless, symptoms had worsened. The patient’s wife
said that her husband was a smoker for 25 years, who consumes an estimated
10 sticks per day and drinks alcohol for at least 3x a week for 9 years already.
She said that her husband has been alcoholic since he was diagnosed DM type
2. She also stated that her husband was a government employee and never
did any form of exercise instead his vices worsened after he retired. The father
of the patient died 10 years ago due to kidney failure while the mother died 7
years ago due to hypertension. The patient has 3 younger brothers, all of
whom are suffering from diabetes mellitus and hypertension.
September 12, 2024
September 12, 2024 1:30pm
11:30 pm
PHYSICAL EXAMINATION
Vital Signs BP: 180/100 mmHg
RR: 39 cpm
PR: 108 bpm
Temp: 37.5
O2 Sat: 89%
NVS: 11/15
Eyes Swollen and puffy
Ears Tympanic membrane clear, canals clear bilaterally
Nares (+) Flaring
Throat Oropharynx pink and moist; (-) erythema, tonsillar enlargement,
lesions, teeth erosion; normal size of thyroid
Integumentary (+) White, dandruff-like appearance on face and body, itching, (+)
excoriation
Lungs (+) Rales and crackles
Nails Pale
Extremities (+) Bipedal edema grade 4
Neuro Incomprehensible, restless, and agitated
Abdomen (+) abdominal distention with spider web-like veins appearance
Cardiac Increased heart rate, (-) heart murmurs, (-) heart gallops
DIAGNOSTIC INVESTIGATIONS
COMPLETE BLOOD PICTURE
TEST TEST VALUE NORMAL VALUE
Hgb 6 g/dl 13-17 g/dL
RBC 3.79 million/mm3 4.5-5.5 million/ mm3
TLC (WBC) 15600 cells/ mm3 4000-11000 cells/ mm3
DIFFERENTIAL LEUKOCYTE COUNT
Neutrophils 89% 40-80%
Lymphocytes 08% 20-40%
Eosinophils 01% 0-6%
Monocytes 02% 2-10%
ESR 38 mm/hr 0-20 mm/hr
LIVER FUNCTION TESTS
Total Bilirubin 0.7 mg/dL 0.0-1.0 mg/dL
Direct Bilirubin 0.2 mg/dL 0.0-0.25 mg/dL
Indirect Bilirubin 0.5 mg/dL 0.3-1.0 mg/dL
SGPT 55 IU/L 0-45 IU/L
SGOT 23 IU/L 0-40 IU/L
Alkaline Phosphatase 222 IU/L 30-170 IU/L
Total Protein 7.8 g/ dL 6-8 g/dL
Albumin 3.0 g/ dL 3.5-5.5 g/dL
Globulin 4.8 g/ dL 2.3-3.6 g/dL
BLOOD SUGAR TEST
TEST DATE: September 12, 2022 NORMAL VALUE
Fasting 240 mg/ dL 60-110 mg/ dL
Random 315 mg/ dL 80-150 mg/ dL
RENAL FUNCTION TEST
TEST DATE: September 12, 2022 NORMAL VALUE
BUN 110 mg/ dL 10-50 mg/ dL
Creatinine 7.8 mg/ dL 0.6-1.6 mg/ dL
ELECTROLYTES
TEST DATE: September 12, 2022 NORMAL VALUE
Sodium 139 135-145 mEq/L
Chloride 105 105 mEq/L
Potassium 5.9 5.2 mEq/L
Calcium 9.0 9-11 mg/dL
URINE ANALYSIS
Color Light yellow
Reaction Acidic
Albumin Traces
Sugar ++ (2) plus
Deposit Cells 4-5 pus cells/HPF
3-4 epithelial cells/HPF
Casts Nil
Crystals Nil
Ketone -ve
RBC -ve
X-RAY CHEST APA VIEW
Impression Pneumonia. Correlate with findings.
CPB PERIPHERAL SMEAR
WBC Neutrophilic leukocytosis
RBC Normocytic hypochromic with anisocytosis
PLATELETS Mild thrombocytosis
Impression: Normocytic normochromic anemia with neutrophilic leukocytosis
Roentgenography Image
Electrocardiogram Result
Blood Gas Analysis Result
Lipid Profile Result
Blood Typing Result
COVID-19 Test Result
UTZ Result
What to Do?
To immerse yourself in the care management of your patient, let us do some detailed
description of your patient care tasks. Using the Case Scenario assigned to you, you
are expected to perform the following:
1. Fill-up the needed data based on the given scenario/case.
2. Conduct a history taking and physical assessment of your patient. Discuss
the health history of the patient narratively, in chronological order as much as
possible. Use the ROS and Health Assessment form for documenting PA
findings.
3. Discuss the pathophysiology of the patient’s condition. Discuss the FF:
definition of diagnosis, etiology, symptomatology, schematic diagram of the
pathophysiology of the condition of the patient, narrative description of the
condition of the patient.
4. Interpret the therapeutics done for the patient: doctor’s orders, laboratory and
diagnostic tests done, and surgical procedures to be performed.
5. Present your drug study and IVF [Link] the IVF and medications
in the appropriate sheets.
6. Formulate at least 3 Nursing Diagnosis, patient-centered care plan for your
patient. Integrate in your care intervention significant bioethical and legal
standards of patient care.
7. Document the care given by making a nurse documentation following the
FDAR format.
8. Clinical Reasoning Questions - Collaboration: Patients with CKD usually
have very low hemoglobin. The physician ordered 3 units of FWB transfuse after
proper screening and crossmatching. The patient’s blood type is B+ as reflected
in the laboratory result. The nurse in charge, plans to transfuse it immediately
to the patient without 2 nurses verifying it due to lack of staff nurses and high
census.
9. Clinical Reasoning Questions - Ethico-Moral-Legal: On the first day of
duty, while preparing your medications to your patient, you found out that the
ticket for Spironolactone is not yet discarded. You remember during
endorsement that the Spironolactone of your patient was shifted to Furosemide
since yesterday. You informed and clarified this to the medicating nurse, she
then discarded the ticket and said “Hala na-pirmahan ko na yan kahapon pa. Ay
hayaan mo na. Magstart nalang tayo ng Furosemide. Pareho lang namn yang
pampa-ihi. Gawan mo ako ng ticket sir. Salamat ha.” What would be your
nursing action in this scenario? What ethical principle/s is/are applicable in this
scenario? Justify. Answer narratively.
Have you answered all the questions above? Great! Congratulations! You
have completed this module. You may now proceed to the next activity for the week.
Please wait for further instructions from you instructor
References:
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s fundamentals of nursing:
Concepts, process, and practice (10th ed.). Pearson Education, Inc.
Hinkle, J. & Cheever, K. (2018). Brunner and Suddarth’s textbook of medical-surgical
nursing (15th ed.). Wolters Kluwer
Marieb, E., & Keller, S. (2017). Essentials of human anatomy & physiology (12th ed.).
Retrieved from [Link]
Quigley, B., Palm, M.L., & Bickley, L. (2012). Bates’ nursing guide to physical
examination and history taking (1st ed.). Wolters Kluwer Health
S, Smeltzer, et. Al., (2014) Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing (12th ed.)
