Ckd Uti Non-obstructive Nephropathy

8/8/2019 Ckd Uti Non-obstructive Nephropathy

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I. INTRODUCTION

a. brief discussion of the diseaseThe kidneys are located retroperitoneal, in the posterior aspect of the

abdomen, on either side of the vertebral column. They lie between the twelfth

thoracic and the third lumbar vertebrae. The left kidney is usually positioned

slightly higher than the right because of the position of the liver.

The kidneys balance the urinary excretion of substances against the

accumulation within the body through ingestion or production. Consequently,

they are a major controller of fluid and electrolyte homeostasis. The kidneys also

have several non-excretory metabolic and endocrine functions, including blood

pressure regulation, erythropoietin production, insulin degradation, prostaglandin

synthesis, and vitamin D metabolism.

Chronic kidney disease (CKD), also known as chronic renal disease, is a

progressive loss of renal function over a period of months or years. The

symptoms of worsening kidney function are unspecific, and might include feeling

generally unwell and experiencing a reduced appetite . Often, chronic kidney

disease is diagnosed as a result of screening of people known to be at risk of
http://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Malaisehttp://en.wikipedia.org/wiki/Anorexia_(symptom)http://en.wikipedia.org/wiki/Screening_(medicine)http://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Malaisehttp://en.wikipedia.org/wiki/Anorexia_(symptom)http://en.wikipedia.org/wiki/Screening_(medicine)http://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Diabetes_mellitus


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As the kidney function decreases blood pressure is increased due to fluid

overload and production of vasoactive hormones, Erythropoietin synthesis is

decreased (potentially leading to anemia , which causes fatigue ). People with

chronic kidney disease suffer from accelerated atherosclerosis and are more

likely to develop cardiovascular disease than the general population. Urinary tract

infection (UTI) is a bacterial infection that affects any part of the urinary tract . The

main etiologic agent is Escherichia coli. Although urine contains a variety of

fluids, salts, and waste products, it does not usually have bacteria in it. [1] When

bacteria gets into the bladder or kidney and multiply in the urine, they may cause

an UTI. Symptoms include frequent feeling and/or need to urinate, pain during

urination, and cloudy urine. [3]

The most common symptoms of a bladder infection are burning with urination

(dysuria ), frequency of urination, an urge to urinate. Nephropathy refers to

damage to or disease of the kidney . An older term for this is nephrosis.

b. Reasons for choosing the case

As student nurses, we chose CKD as our case because we want to

have an in depth understanding of the disease in order to improve our

knowledge as a basis of health teachings to our future patient having
http://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Erythropoietinhttp://en.wikipedia.org/wiki/Anemiahttp://en.wikipedia.org/wiki/Fatigue_(physical)http://en.wikipedia.org/wiki/Atherosclerosishttp://en.wikipedia.org/wiki/Cardiovascular_diseasehttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Urinary_tracthttp://en.wikipedia.org/wiki/Escherichia_colihttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Urinary_tract_infection#cite_note-0http://en.wikipedia.org/wiki/Urinary_bladderhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Urinary_tract_infection#cite_note-2http://en.wikipedia.org/wiki/Dysuriahttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Erythropoietinhttp://en.wikipedia.org/wiki/Anemiahttp://en.wikipedia.org/wiki/Fatigue_(physical)http://en.wikipedia.org/wiki/Atherosclerosishttp://en.wikipedia.org/wiki/Cardiovascular_diseasehttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Urinary_tracthttp://en.wikipedia.org/wiki/Escherichia_colihttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Urinary_tract_infection#cite_note-0http://en.wikipedia.org/wiki/Urinary_bladderhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Urinary_tract_infection#cite_note-2http://en.wikipedia.org/wiki/Dysuriahttp://en.wikipedia.org/wiki/Kidney


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c. Statistics

Mean level of GFR by age group:

Philippine vs. US data.

Age Group

in Years

NNHeS 2003

Philippines

NHANES III

U.S.A.

20-29 119 116

30-39 109 107

40-49 103 99

50-59 100 93

60-69 86 85

70+ 77 75


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Mortality

Number of deaths from nephritis, nephrotic syndrome, andnephrosis: 45,344

Deaths per 100,000 population: 15.1 Cause of death rank: 9

d. Nurse-Centered Objectives

1. To gather enough data and information upon assessment.

2. To understand chronic kidney disease, its causes and

pathophysiology.

3. To familiarize with the possible complications, signs and

symptoms of the problem

4. To design a plan of care for patient with CKD.

5. To have a thorough understanding of the case of the patient,

the medical management and the necessary health teachings

to the patient


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I. Nursing History

1. Personal History

Demographic Data

Purple, 65 years of age, was born on April 13, 1945 in a government hospital, a

Roman Catholic, and a natural born Filipino citizen. Her husband Blue died at the age

of 65 years old because of vehicular accident. She is currently residing at Angeles

City. She has 4 children, namely Black (eldest), Yellow, (25 years old), Green (20

years old) and Red (19 years old). However, her eldest son Black died at the age of 27years old due to lung collapse. Purple was brought in one of the private hospitals in

Angeles City last July 6, 2010 with a diagnosis of Chronic Kidney disease secondary to


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Purple manages their sari-sari store. According to her, she earns an average of

P 7, 000 a month. Her daughter Yellow works as a call center agent and earns P10,

000. On the other hand, her son Green works as a computer technician in one of the

companies at Clark. He earns at around P8, 000 on a monthly basis. Her youngest

daughter is unemployed. Most of the income is allotted for food and monthly bills.

When it comes to dietary habits, the patient is fond of eating spicy foods, and junk

foods, and sweets. She is also fond of drinking sodas. Purple had been smoking for 20

years. She consumes an average of 2 sticks a day.

Purple does not believe on herbularyos and faith healers. She buys

over-the-counter drugs if a family member catches colds, cough or fever. When any of

the family members get seriously sick, she consults the doctor.


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Lavender DM, RF

2. Family-Health Illness History

Schematic diagram

Legends:

= female

= male

MagentaDM, HPN

IndigoDM, HPN

VioletARTH, RF

WhiteRF, ARTH

GreyHPN, DM

PurpleARTH, HPN,CKD 2 UTI


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Purples eldest sister, Violet, had arthritis and died at the age of 40 due to

renal failure. Indigo has diabetes and hypertension. Magenta, like her brother Indigo,

has diabetes and hypertension. The youngest among the 5 siblings, Lavender, had

diabetes and died at an age of 32 years old due to renal failure.


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History of past illness

According to Purple, during the first month of June 2010, sheexperienced urgency to urinate accompanied by flank pain, burning sensationon urination and fever. She also experienced joint pains wherein she sometimesfinds difficulty to walk and perform activities of daily living such as doinghousehold chores. She did not consulted the physician immediately because shethought that it is just normal because of old age, and that her difficulty inurinating is only brought about menopause. She took paracetamol to relievefever, and drank "buko juice" to releive the burning sensation duringmicturation. Her daughter adviced her to drink 8 glass of water everyday, butPurple said she can only consume an average of 4 glasses a day. After 5 days,her fever has subsided, however, she still experience pain when voiding. Also,despite of her feeling that her bladder is full, she only voids little amount of urine. In addition, she said that her urine is dark yellow in color. On June 8,sheconsulted the doctor. She had her urine and blood tested. The physician toldher that her urine has pus, RBCs and protein. She was then diagnosed of havingUTI. The physician prescribed her antibiotics and adviced her to return after aweek for follow-up check up.History of Present Illness

On June 13, 2010, Purple said that she still experiences pain whenurinating. She felt weak. Her daughter noticed that she appears pale so shebrought her to the hospital. Her vital signs were taken and results revealed ablood pressure of 140/90 mmHg and her temperature was 38.5C. Purple said

that she could not believe it since her usual blood pressure is 120/80mmHg.Urinalysis, stool exam and CBC was done. She was then admitted with adiagnosis of Chronic Kidney Disease, UTI, non-obstructive nephropathy. OnJune 15, foley catheter was inserted and her fever subsided. She was


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Vital Signs:

T: 37.7 C

PR: 92 bpm

RR: 22 cpm

1 st Nurse-Patient Interaction

July 14, 2010

Received lying on bed awake and coherent with Vital Signs of:

T: 37.5 C

PR 86 b


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Generally round

absence of nodule

No tenderness noted upon palpation

Scalp

No scars noted

No lesions noted

No tenderness or masses upon palpation.

Hair

Hair is black in color

Evenly distributed covers the whole scalp

With dry coarse short hair


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The ear lobes are bean shaped, parallel, and symmetrical auricle

is higher that the outer cantus of the eye, mobile, firm and

tender

Skin is same in color as in the complexion

No lesions noted on inspection

Nose

No Discharges

No nasal flaring noted

Both nares are patent

No tenderness and no lesions

Mouth


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Abdomen

Skin color is uniform, no lesions

rounded and symmetrical with no masses

Urinary

urine is light yellow in color

190ml in a 8hr shift

Extremities

Trimmed fingernails and toenails with no clubbing on both hands


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PR: 91 bpm

RR: 21 cpm

Integumentary

Skin warm to touch

thin brittle nails

coarse thinning hair

Skull

Generally round

absence of nodule

No tenderness noted upon palpation

Scalp

No scars noted


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Face is oval in shape

with symmetrical facial structures

Eyes

Evenly placed and in line with each other

Non-protruding

Ears

The ear lobes are bean shaped, parallel, and symmetrical auricle

is higher that the outer cantus of the eye, mobile, firm and

tender

Skin is same in color as in the complexion

No lesions noted on inspection

Nose


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With brownish gums

With yellowish discolored teeth

Neck

No palpable and visible mass or lumps

No palpable lymph nodes

Abdomen

Skin color is uniform, no lesions

rounded and symmetrical with no masses

Extremities

Trimmed fingernails and toenails with no clubbing on both hands

and feet


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II. Diagnostic And Laboratory Procedures

DIAGNOSTIC/LABORATORYPROCEDURE INDICATION/PURPOSE

DATEORDERED/

DATERESULTS

WERERELEASED

RESULTS

NORMALVALUES(UNITS

USED INTHE

HOSPITAL)

ANALYSIS ANDINTERPRETATION

RESULTS

Hematology

Hemoglobin To determine the amountof oxygen carried byRBCs.

D.O.:June 8, 2010D.R:June 8, 2010

9.3 d/dl 11.6 - 15.5g/dl

The hemoglobin thatis present in the

blood is slightlylower than thenormal level. Thisindicates disruptionin the production of erythropoietin in the

body, a special cellsin the kidney thatmonitor the oxygenconcentration in

blood resulting fromchronic kidneydisease.

Hematocrit To measure theconcentration of RBCwithin the blood volume

D.O.:June 8, 2010D.R:

27.9 % 36.47% The level of hematocrit is lower than the normal
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and evaluate hydationstatus. It also indicates

presence of anemia which

is one of the commoncomplication of chronickidney disease.

June 8, 2010 level. Thus,indicating lower RBC concentration

in the blood due todecreased ability of the kidneys to

produceerythropoietin, ahormone thatstimulates the

production of RBC.Red Blood Cells To determine amount of

Red blood cells, the blood

cell that carries oxygen.

D.O.:June 8, 2010

D.R:June 8, 2010

3.0 x 1012/L 4.2 5.4/L The level of RBC islower than the

normal level. Thisindicates decreasederythropoietin

production whichstimulates the bonemarrow to produceRBC due to chronickidney disease.

White Blood Cells To determine the presence of infection. It

was also use to monitor the bodys response totreatment and monitor

bone marrow functionand immune response.

D.O.:June 8, 2010

D.R:June 8, 2010

11.08 x109/liter

4.8 10.8 x109/liter

The level of WBC ishigher than the

normal level, thismight be due toIncreased levels of uremic toxinsresulting from CKDthat could impairedthe immune andinflammatory


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response causinginfection.

Neutrophils To determine the

neutrophils, a polymorphonuclear leukocytes that help the

body fight infections andother diseases.

D.O.:

June 8, 2010D.R:June 8, 2010

91 40 74 The level of

neutrophils is higher than the normallevel. Thus,indicating presenceof infection in the

body due to the presence of uremiain the blood.

Lymphocytes This measured todetermine if theres a

lowered immune status inthe patient.

D.O.:June 8, 2010

D.R:June 8, 2010

4.9 19 - 48 The lymphocytelevel in the blood is

lower than thenormal level. Thisindicates loweredimmune status of the

patient.
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A. HEMATOLOGY

Nursing Responsibilities

BEFORE:

Check the doctors order.

Identify the patient.

Inform the patient and/or SO before doing the procedure and adequately explain the importance andpurpose of doing such procedure.

Inform that there is no food/fluid restriction before the test.

Inform that the test requires blood sample and that she may experience transient discomfort fromneedle puncture.

DURING:Adhere to standard precautions which include:

Applying sterile technique.

Make sure to have patients pertinent information in the container.

AFTER:Apply direct pressure on the venipuncture site.

Send the specimen immediately to the laboratory and fill-out laboratory forms properly and adequately.


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Chart all procedures done.

B. URINALYSIS

Nursing Responsibilities

BEFORE:

Explain to the patient what test to be done, its purpose and how it is done.

Inform the patient that the test require a urine specimen.

Instruct the patient how is the proper way to collect urine specimen.

Provide a clear container for the specimen.

DURING:Adhere to standard precautions which include:


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Applying sterile technique.

Collect the specimen properly.

AFTER:Label properly together with the laboratory slip.

Send the specimen to the laboratory.

Chart time of collection and attach results to chart as soon as they are available.


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DIAGNOSTIC/LABORATORY

PROCEDUREINDICATION/PURPOSE

DATEORDERED/

DATE

RESULTSWERERELEASED

RESULTS

NORMALVALUES(UNITS

USED INTHEHOSPITAL)


RESULTS

Hematology


D.O.:June 13, 2010D.R:June 13, 2010

11.1 d/dl 11.6 - 15.5g/dl


blood is slightlylower than thenormal level. This

indicates disruptionin the production of erythropoietin in the


blood resulting fromchronic kidneydisease.

Hematocrit To measure theconcentration of RBCwithin the blood volumeand evaluate hydationstatus. It also indicates

presence of anemia whichis one of the commoncomplication of chronic

D.O.:June13, 2010D.R:June 13, 2010

33.9 % 36.47% The level of hematocrit is lower than the normallevel. Thus,indicating lower RBC concentrationin the blood due todecreased ability of


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kidney disease. the kidneys to produceerythropoietin, a

hormone thatstimulates the production of RBC.

Red Blood Cells To determine amount of Red blood cells, the bloodcell that carries oxygen.

D.O.:June 13, 2010D.R:June 13, 2010

3.0 x 1012/L 4.2 5.4/L The level of RBC islower than thenormal level. Thisindicates decreasederythropoietin

production whichstimulates the bone

marrow to produceRBC due to chronickidney disease.

White Blood Cells To determine the presence of infection. Itwas also use to monitor the bodys response totreatment and monitor

bone marrow functionand immune response.

D.O.:June 13, 2010D.R:June 13, 2010

11.08 x109/liter

4.8 10.8 x109/liter

The level of WBC ishigher than thenormal level, thismight be due toIncreased levels of uremic toxinsresulting from CKD

that could impairedthe immune andinflammatoryresponse causinginfection.

Neutrophils To determine theneutrophils, a

polymorphonuclear

D.O.:June 13, 2010D.R:

91 40 74 The level of neutrophils is higher than the normal


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leukocytes that help the body fight infections andother diseases.

June 13, 2010 level. Thus,indicating presenceof infection in the

body due to the presence of uremiain the blood.

Lymphocytes This measured todetermine if theres alowered immune status inthe patient.

D.O.:June 13, 2010D.R:June 13, 2010

4.9 19 - 48 The lymphocytelevel in the blood islower than thenormal level. Thisindicates loweredimmune status of the

patient.


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DATEORDERED/

DATERESULTSWERE

RELEASED

RESULTS

NORMALVALUES

(UNITSUSED INTHE

HOSPITAL)


RESULTS

Hematology


D.O.:June 13, 2010D.R:June 13, 2010

9.3 d/dl 11.6 - 15.5g/dl


blood is slightlylower than the

normal level. Thisindicates disruptionin the production of erythropoietin in the


blood resulting fromchronic kidney

disease.Hematocrit To measure theconcentration of RBCwithin the blood volumeand evaluate hydationstatus. It also indicates

presence of anemia whichis one of the common

D.O.:June 13, 2010D.R:June 13, 2010

27.9 % 36.47% The level of hematocrit is lower than the normallevel. Thus,indicating lower RBC concentrationin the blood due to


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complication of chronickidney disease.

decreased ability of the kidneys to

produce

erythropoietin,ahormone thatstimulates the

production of RBC.Red Blood Cells To determine amount of

Red blood cells, the bloodcell that carries oxygen.

D.O.:June 13, 2010D.R:June 13, 2010

3.0 x 1012/L 4.2 5.4/L The level of RBC islower than thenormal level. Thisindicates decreasederythropoietin

production which

stimulates the bonemarrow to produceRBC due to chronickidney disease.

White Blood Cells To determine the presence of infection. Itwas also use to monitor the bodys response totreatment and monitor

bone marrow function

and immune response.

D.O.:June 13, 2010D.R:June 13, 2010

11.08 x109/liter

4.8 10.8 x109/liter

The level of WBC ishigher than thenormal level, thismight be due toIncreased levels of uremic toxins

resulting from CKDthat could impairedthe immune andinflammatoryresponse causinginfection.

Neutrophils To determine theneutrophils,a

D.O.:June 13, 2010

91 40 74 The level of neutrophils is higher


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polymorphonuclear leukocytes that help the

body fight infections and

other diseases.

D.R:June 13, 2010

than the normallevel. Thus,indicating presence

of infection in the body due to the presence of uremiain the blood.

Lymphocytes This measured todetermine if theres alowered immune status inthe patient.

D.O.:June 13, 2010D.R:June 13, 2010

4.9 19 - 48 The lymphocytelevel in the blood islower than thenormal level. Thisindicates loweredimmune status of the

patient.


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DATEORDERED/

DATERESULTS

WERE

RELEASED

RESULTS

NORMALVALUES(UNITS

USED INTHE

HOSPITAL)


RESULTS

Urinalysis This is used as ascreening and/or diagnostic tool which canhelp detect if the patientis experiencing anygenitourinary problemslike UTI or detect if

patient has DM or co-morbid conditions whic

affect in the clientstreatment and diganosis.

D.O.:June 13, 2010D.R:June 13, 2010

Color: dark yellowSlightlyturbidPus cells: 10-13 HPFRed cells : 1-2 HPF

CRCL:65ml/min

Protein:11 mg/dL

0-5 HPF

absent

87-107ml/min

0.8 mg/dl

the presence of puscells is due toinfection broughtabout by theinvasion of microorganism onthe urinary tract.

Presence of RBC is

brought aboutimpaired glomerular function secondaryto tubular necrosisleading to scarring of nephrons.

Proteinuria resultsfrom the impairedfunction of the

glomerulus, wherein protein is excreted inthe urine.

Low creatinineclearance resultsfrom decrease inGFR.


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DATEORDERED/

DATERESULTS

WERERELEASED

RESULTS

NORMALVALUES

(UNITS USEDIN THE

HOSPITAL)


RESULTS


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Creatinine Use to measure GFR.To measure kidneyfunction.

D.O.:June 13,2010

D.R:June 13,2010

18.3 mg/dl 0.5-7 mg/dl The result is abovethe normal limit.An increase in the

level of Creatinineindicates impairedkidney function toexcrete excessivecreatininetherefore, itaccumulates onthe blood.

BUN Measures the renalexcretion of urea

nitrogen, which is a by-product of proteinmetabolism. Itindicates extent of renal clearance of thisnitrogenous wasteproduct.

D.O.:June 13,

2010D.R:June 13,2010

100 mg/dl 10-20mg/dl An increase inlevel of BUN

signifies that thekidney is unable toexcrete wasteproduct frommetabolism due toimpairedglomerularfunction.

K D.O.:June 13,

2010D.R:June 13,2010

7mmol/L 3.5-5mmol/L Hyperkalemiaresults from

decreaseglomerularfiltration ratewherein excesspotassium is notexcreted in theurine.


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ABG6/14/10

Results Normal Values

pH 7.367 7.35-7.45 pCO2 16.7 35-45mmHg pO2 101.01 80-100 mmHgHCO3 9.4 22-26mEq/L

ABG Impression: Metabolic acidosisX-Ray 6/14/10-No abnormal densities seen in the parenchyma of both lungs. Heart enlarged. Aorta is calcified;Impression: CardiomegalyUTZ 6/14/10

Kidneys and urinary bladder- both kidneys are small in sizes exhibiting diffuse increased parenchyma echogenecity. Theconsticomedullary differentiation. Both kidneys are well distinct. The renal parenchyma thickness are within normal limits. No solidmass aptic lesion or calculus noted.The right kidney measures about 8.2x3.1x3.2 cm with cortical thickness of 1.5cm while the left kidney measures about 7.6x2.8x3.2cmwith cortical thickness of 1cm.The urinary bladder is well distended with smooth mucosal lining. Intraluminal mass or calculus seen. The wall is not thickened. Postvoid volume is 1046ml. The patient hard urinated 64 the ultrasound study.Impression:-Small sized kidney with diffuse parenchymal disease; bilateral.-Mild hydronephrosis, Right kidney, urinary retention.


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V. Anatomy and Physiology

The Kidney

The urinary system functions to

create urine, store it, and carry itout of the body. It is made up of two kidneys, two ureters, the

bladder, two sphincter muscles,and the urethra. Illustrationadapted from drawing of kidney

from the Nat'l Istitute of Diabetes and Digestive and Kidney Diseas, National Instituteof Health

The kidneys are bean-shapedorgans, each about the size of

your fist. They are located near the middle of your back, just below the rib cage.

Kidneys remove wastes and extra water from the blood to form urine. About 2 quarts of urine is made each day from filtering about 200 quarts of blood through the kidneys. If your kidneys did not remove these wastes, the wastes would build up in the blood andyou would eventually die. Some people have serious health problems if they have less


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Urination normally begins voluntarily, by muscle contraction, pushing the urine out of the bladder, causing the sphinctor to open. Once urination begins, the urine flows fromthe bladder, past the now open urethral spinctor, and out of the body through the urethra.

Cardiovascular System Anatomy & Physiology

The heart is the pump responsible for maintaining adequate circulation of oxygenated blood around the vascular network of the body. It is a four-chamber pump,with the right side receiving deoxygenated blood from the body at low presure and

pumping it to the lungs (the pulmonary circulation) and the left side receiving oxygenated blood from the lungs and pumping it at high pressure around the body (the systemiccirculation).

The myocardium (cardiac muscle) is a specialised form of muscle, consisting of individual cells joined by electrical connections. The contraction of each cell is produced

by a rise in intracellular calcium concentration leading to spontaneous depolarisation, andas each cell is electrically connected to its neighbour, contraction of one cell leads to awave of depolarisation and contraction across the myocardium.

This depolarisation and contraction of the heart is controlled by a specialisedgroup of cells localised in the sino-atrial node in the right atrium - the pacemaker cells .

1. These cells generate a rhythmical depolarisation, which thenspreads out over the atria to the atrio-ventricular node.

2. The atria then contract, pushing blood into the ventricles.


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The ECG

The Electrocardiograph (ECG) is clinically very useful, as it shows the electricalactivity within the heart, simply by placing electrodes at various points on the bodysurface. This enables clinicians to determine the state of the conducting system and of themyocardium itself, as damage to the myocardium alters the way the impulses travelthrough it.

When looking at an ECG, it is often helpful to remember that an upwarddeflection on the ECG represents depolarisation moving towards the viewing electrode,and a downward deflection represents depolarisation moving away from the viewingelectrode. Below is a normal lead II ECG.

The P wave represents atrial depolarisation- there islittle muscle in the atrium so the deflection is small.

The Q wave represents depolarisation at the bundle of His; again, this is small as there is little muscle there.

The R wave represents the main spread of depolarisation, from the inside out, through the base of the ventricles. This involves large ammounts of muscle so the deflection is large.

The S wave shows the subsequent depolarisation of the rest of the ventricles upwards from the base of theventricles.

The T wave represents repolarisation of themyocardium after systole is complete. This is a


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The heart needs its own reliable blood supply in order to keep beating- the

coronary circulation. There are two main coronary arteries, the left and right coronaryarteries, and these branch further to form several major branches (see image) . Thecoronary arteries lie in grooves (sulci) running over the surface of the myocardium,covered over by the epicardium, and have many branches which terminate in arteriolessupplying the vast capillary network of the myocardium. Even though these vessels havemultiple anastomoses, significant obstruction to one or other of the main branches willlead to ischaemia in the area supplied by that branch.


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Pathophysiology: CKD UTI non-obstructive nephropathyBook-based

Predisposing factors:Gender AgeHereditaryAutoimmune disorders

Neurogenic bladder

Precipitating factors:AllergiesDietHygiene

Sexual activityInstrumentationPregnancyRheumatic Heart DiseaseFrequent sore throatObstructionKidney/ urinary tract stonesVesiculoureteral refluxDMDHN

Bacteria triggers inflammatory response

Edema and swelling

of involved tissues

Bacteria gains access to blood andgoes to the kidney through systemic

circulation

Intestinal, exogenous or genito-urinary m.o goes to the kidney

through ureters and bladder

InfectionTubular cell

necrosis

Fib i / i

Increase WBCDysuria

i

Urinary freq.,Cloudy urine

Fever


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proteinuriahematuria Activationof RAAS

Edema Na and water retention

vasoconstriction

Increase in blood pressure

Respiratory andcardiacmanifestations

More urea isabsorbed; decreaseexcretion of uricacid

IncreaseBUN, and

CREA level

Deposition of uric acid on

joints or softtissue (goutyarthritis)

oliguria

P and Caimbalance

hyperkale

mia

Cardiomegalydue to LVH

Confusion,difficultyconcentrating,seizure, coma

oliguria


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IV. THE PATIENTS ILLNESS

SYNTHESIS OF THE DISEASESYNTHESIS OF THE DISEASE

Pyelonephritis is a Bacterial infection of the kidney. Pyelonephritis can beacute (sudden) or chronic (slow, subtle, and stubborn). It is most often due tothe ascent of bacteria from the bladder up the ureters to infect the kidneys.

The symptoms of pyelonephritis include flank (side) pain, fever, shaking chills,sometimes foul-smelling urine, urgency (to urinate), frequency (urinating), andgeneral malaise. Tenderness is elicited on gently tapping over the kidney witha fist (percussion).

Glomerulonephritis is the term used to describe a group of diseases that

damage the part of the kidney that filters blood. When the kidney is damaged,it cannot get rid of wastes and extra fluid in the body. If the illness continues,the kidneys may stop working completely. Some other terms you may hear usedare nephritis and nephrotic syndrome. Glomerular diseases damage theglomeruli, letting protein and sometimes red blood cells leak into the urine.Sometimes a glomerular disease also interferes with the clearance of waste

products by the kidney, so they begin to build up in the blood. Furthermore,loss of blood proteins like albumin in the urine can result in a fall in their levelin the bloodstream. In normal blood, albumin acts like a sponge, drawing extra


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intravascular space to the interstitial space because of decreased oncoticpressure. As a response to decreased GFR, aldosterone is released from the

adrenal cortex, causing the

kidneys to reabsorb sodium and water. Fluidretention in turn results in the development of respiratory and cardiovascularclinical manifestations

Acid-Base BalanceMetabolic acidosis is associated with CKD because the tubules cannot excretehydrogen ions (H +), resulting in the use of bicarbonate (HCO3) anions tomaintain acid-base balance. Two other buffering systems are in place that

assist in compensating for

the acidosis. Hydrogen ions combine with ammoniaproduced in the renal tubule cells to form ammonium, which combines withchloride and is excreted in the urine. This mechanism helps to remove H + whilegenerating HCO 3. However, because of impaired nephron function, excretion of ammonium is decreased. The third mechanism involved with acid-base balanceresults in H + combining with phosphate (one of the bodys buffering systems).Metabolic acidosis also contributes to a shift of calcium from the bone, allowingH+ to enter and be buffered in the bone.

Electrolyte BalanceMultiple electrolyte levels are altered in patients with CKD. Potassium levelsmay be normal until late in ESRD, and elevated potassium levels are oftenassociated with CKD because of the inability of the kidney to excrete potassiumas a result of decreased GFR. In addition, when metabolic acidosis is present,potassium ions shift from the intracellular compartment to the extracellularspace in exchange for H +, in an effort to maintain extra-cellular acid-basebalance.

The third mechanism that affects serum levels of calcium is the endocrine


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Anemia results from several factors in patients with CKD. The peritubular

capillary endothelium in the kidneys produces erythropoietin,

which is neededto stimulate bone marrow to release red blood cells. In addition, uremiainactivates erythropoietin. Failure of this mechanism results in anormochromic, normocytic anemia. Uremia can also contribute to anemia byshortening the life span of the red blood cells. Finally, the low hemoglobinlevel contributes to acidosis, because less hemoglobin is available in the bodyto buffer acids.

CardiovascularHypertension is a result of increased fluid retention and stimulation of therenin-angiotensin-aldosterone system. In addition, hypertension can lead to thedevelopment of CKD..

RespiratoryAn increased respiratory rate may result from fluid overload, as a compensatorymechanism for metabolic acidosis, or from decreased PaO 2. Although notidentified as Kussmaul respirations, deep breaths associated with metabolicacidosis occur as a compensatory mechanism to eliminate carbon dioxide.

GastrointestinalAnorexia, weight loss, nausea, and vomiting are frequent findings in patientswith CKD, Gastrointestinal bleeding from altered platelet function andincreased gastric acid secretion from increased release of parathyroid hormonemay occur. The focus of the nursing assessment includes inspecting oral mucousmembranes, monitoring weight, checking stool for occult blood, and notingbreath odor.


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ineffective conversion of vitamin D to allow absorption of calcium. Three bonechanges are associated with this syndrome: (1) osteomalacia due to inadequate

absorption of calcium from

the gastrointestinal tract, (2) osteitis fibrosa orbone demineralization due to increased parathyroid hormone, and (3)osteosclerosis, which is manifested as bands of increased and decreased bonedensity in the vertebrae.

HematologicalDecreased erythropoietin levels result in anemia.

ImmunologicalIncreased levels of uremic toxins can lead to impaired immune andinflammatory responses with resultant defects in granulocytes, impaired B- andT-cell functioning, and impaired phagocytosis.The focus of the nursingassessment is examination for signs or symptoms of an impaired inflammatoryand infectious response. Infection is a common occurrence in patients with CKDthat often results in hospitalization and death.

RenalIn patients with CKD, urinary signs and symptoms are related to fluid balance;as GFR decreases, urine output decreases. Retention of waste products such asurea nitrogen and creatinine leads to azotemia, whereas uric acid retentionmay lead to gout. Proteinuria and hematuria were discussed previously. Thefocus of the nursing assessment is fluid balance (intake and output, dailyweight, edema) and monitoring of laboratory results.


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Pathophysiology: CKD UTI non-obstructive nephropathy

Client-centered

Predisposing factors:Female65 yrs. old (menopause)Mother had RF

Precipitating factors:Eats spicy foods, junk foods,and drinks sodasCatheter for 1 month

Bacteria triggers inflammatory response

Edema and swellingof involved tissues

Bacteria gains access to blood andgoes to the kidney through systemic

circulation

Intestinal, exogenous or genito-urinary m.o goes to the kidney

through ureters and bladder

InfectionTubular cellnecrosis

Increase WBC11 08 109/lit

Fever38.5 June 13

Pus Cells10-13 HPF, June13


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Proteinuria11 mg/dL

Hematuria1-2 HPFJune 13

Activation of RAAS

Edema on left upperextremity, bipedal

edema, june 14

Na and water retention

vasoconstriction

Increase BP140/90 mmHgJune 13, 14

Urea notexcreted

BUN= 100mg/dlCREA=

18.3mg/dl Deposition of

uric acid on joints or softtissue

Oliguria190ml on8 hour shiftJune 14

Hyperkalemia7mmol/L

Cardiomegalydue to LVH

June 14

Joint pain,swelling on

great toeJune 1-5

decreaseexcretionof uricacid


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SYNTHESIS OF THE DISEASESYNTHESIS OF THE DISEASE

Pyelonephritis is a Bacterial infection of the kidney. Pyelonephritis can beacute (sudden) or chronic (slow, subtle, and stubborn). It is most often due tothe ascent of bacteria from the bladder up the ureters to infect the kidneys.

The symptoms of pyelonephritis include flank (side) pain, fever, shaking chills,sometimes foul-smelling urine, urgency (to urinate), frequency (urinating), andgeneral malaise. Tenderness is elicited on gently tapping over the kidney with

a fist (percussion).

Glomerulonephritis is the term used to describe a group of diseases thatdamage the part of the kidney that filters blood. When the kidney is damaged,it cannot get rid of wastes and extra fluid in the body. If the illness continues,the kidneys may stop working completely. Some other terms you may hear usedare nephritis and nephrotic syndrome. Glomerular diseases damage theglomeruli, letting protein and sometimes red blood cells leak into the urine.Sometimes a glomerular disease also interferes with the clearance of wasteproducts by the kidney, so they begin to build up in the blood. Furthermore,loss of blood proteins like albumin in the urine can result in a fall in their levelin the bloodstream. In normal blood, albumin acts like a sponge, drawing extrafluid from the body into the bloodstream, where it remains until the kidneys

remove it. But when albumin leaks into the urine, the blood loses its capacityto absorb extra fluid from the body. Fluid can accumulate outside thecirculatory system in the face, hands, feet, or ankles and cause swelling.


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retention in turn results in the development of respiratory and cardiovascularclinical manifestations

Acid-Base BalanceMetabolic acidosis is associated with CKD because the tubules cannot excretehydrogen ions (H +), resulting in the use of bicarbonate (HCO3) anions tomaintain acid-base balance. Two other buffering systems are in place thatassist in compensating for the acidosis. Hydrogen ions combine with ammoniaproduced in the renal tubule cells to form ammonium, which combines withchloride and is excreted in the urine. This mechanism helps to remove H + while

generating HCO 3

. However, because

of impaired nephron function, excretion of ammonium is decreased. The third mechanism involved with acid-base balanceresults in H + combining with phosphate (one of the bodys buffering systems).Metabolic acidosis also contributes to a shift of calcium from the bone, allowingH+ to enter and be buffered in the bone.

Electrolyte BalanceMultiple electrolyte levels are altered in patients with CKD. Potassium levelsmay be normal until late in ESRD, and elevated potassium levels are oftenassociated with CKD because of the inability of the kidney to excrete potassiumas a result of decreased GFR. In addition, when metabolic acidosis is present,potassium ions shift from the intracellular compartment to the extracellularspace in exchange for H +, in an effort to maintain extra-cellular acid-basebalance.

The third mechanism that affects serum levels of calcium is the endocrinesystem. When the serum level of calcium decreases, the parathyroid glandincreases its secretion of parathyroid hormone, causing calcium to be releasedfrom the bone and compensating for the decreased serum level of calcium.


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to stimulate bone marrow to release red blood cells. In addition, uremiainactivates erythropoietin. Failure of this mechanism results in anormochromic, normocytic anemia. Uremia can also contribute to anemia byshortening the life span of the red blood cells. Finally, the low hemoglobinlevel contributes to acidosis, because less hemoglobin is available in the bodyto buffer acids.

CardiovascularHypertension is a result of increased fluid retention and stimulation of the

renin-angiotensin-aldosterone system. In addition, hypertension

can lead to thedevelopment of CKD..

RespiratoryAn increased respiratory rate may result from fluid overload, as a compensatorymechanism for metabolic acidosis, or from decreased PaO 2. Although notidentified as Kussmaul respirations, deep breaths associated with metabolicacidosis occur as a compensatory mechanism to eliminate carbon dioxide.

GastrointestinalAnorexia, weight loss, nausea, and vomiting are frequent findings in patientswith CKD, Gastrointestinal bleeding from altered platelet function andincreased gastric acid secretion from increased release of parathyroid hormonemay occur. The focus of the nursing assessment includes inspecting oral mucousmembranes, monitoring weight, checking stool for occult blood, and notingbreath odor.

NeurologicalCentral nervous system findings in patients with CKD can range from confusion


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bone demineralization due to increased parathyroid hormone, and (3)osteosclerosis, which is manifested as bands of increased and decreased bonedensity in the vertebrae.

HematologicalDecreased erythropoietin levels result in anemia.

ImmunologicalIncreased levels of uremic toxins can lead to impaired immune andinflammatory responses with resultant defects in granulocytes, impaired B- and

T-cell functioning, and impaired phagocytosis.The focus of the nursingassessment is examination for signs or symptoms of an impaired inflammatoryand infectious response. Infection is a common occurrence in patients with CKDthat often results in hospitalization and death.

RenalIn patients with CKD, urinary signs and symptoms are related to fluid balance;as GFR decreases, urine output decreases. Retention of waste products such asurea nitrogen and creatinine leads to azotemia, whereas uric acid retentionmay lead to gout. Proteinuria and hematuria were discussed previously. Thefocus of the nursing assessment is fluid balance (intake and output, dailyweight, edema) and monitoring of laboratory results.


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A. IVF, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy, etc.

MedicalManagement

General Description Date Ordered/Date Changed

Indication/Purpose Clients Response toTreatment
http://en.wikipedia.org/wiki/Liquid


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1. IV fluidD5 03.

NaCl

2. PNSS

3.BT (PRBC)

It is the giving of liquidsubstances directly intoa vein .

It is the giving of liquidsubstances directly into

a vein . Which has thesame salt content as thenormal body fluid

Blood transfusion is the

Date Ordered:7-13-10DateChanged:7-14-10

Date Ordered:7-14-10

Date Ordered:

It is for rehydration(of fluids andelectrolytes) andcan be for supplementalnourishment, untilthe patient TPN(total parenteralnutrition).

It is isotonic can beused to replace

fluids indehydration, gowith bloodtransfusions,hyponatremia(same osmolarity asour body fluids)

Transfusions are

The patient wassupplied withadequate fluid. Noadverse responsewas noted.

The patient wassupplied with

adequate fluid. Noadverse responsewas noted.

The patient was
http://en.wikipedia.org/wiki/Liquidhttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Liquidhttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Liquidhttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Liquidhttp://en.wikipedia.org/wiki/Vein


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B. DIET

Type of Diet GeneralDescription

DateOrdered/date

Changed

Indcation/Purpose

Clientsresponse totreatment

Uremic Diet

A low-protein

diet can helpremove strainfrom thekidneys,improving thecondition.

Date Ordered:

7-16-10

To sustain in

the body withnutrients asneeded and for the condition of

patients properly diet.

The patient

complied withthe prescribeddiet.

Nursing Responsibilities:

Explain the purpose of food restriction or the prescribed diet to the patient . Mark the Kardex with Uremic Diet Inform the diet nutritionist about the diet status. Inform the patients and family about the diet status.


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Documents

Ckd Uti Non-obstructive Nephropathy