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Hypertensive Nephroschlerosis
A CASE STUDY ON
ANEMIA 2 CHRONIC KIDNEY DISEASE 2
HYPERTENSIVE NEPHROSCHLEROSIS
February 2010
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis
ACKNOWLEDGENMENT
We wish to acknowledge the following for having been part of this wonderful experience:
First and foremost, to our Almighty God who in His wisdom leads us in the right path
and destination.
To the family, for their hospitality and cooperation during our initial assessment and
gathering of data in the hospital. Truly, they have inspired us and paved us a way in realizing
that life is very precious and each second should count.
To the doctors and staff of Southern Philippines Medical Center, for allowing their
institution as one of the training areas for our Related Learning Experience.
To our Clinical Instructor, Ms. Cherry M. Bartolaba, R.N,MAN. who shared her knowledge,
experience and expertise in dealing with our Ward exposure in Southern Philippines Medical
Center. More importantly, for showing us the real value of commitment and guiding us for
this profession.
The North Valley College Foundation Incorporated for allowing us this learning experience
which we will treasure always and bring wherever road will take us.
In to our families and friends, who serves as our inspiration in all endeavors, for their
unconditional support and encouragement.
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis
INTRODUCTION
Anemia is the decrease in the normal number of red blood cells, a decrease in
hematocrit or a decrease in the normal quantity of hemoglobin in the blood. It can also
include the decrease in oxygen-binding ability of each hemoglobin molecule because of the
deformity or lack in the development as in other hemoglobin deficiency.
Because hemoglobin (found inside RBCs) normally carries oxygen from the lungs to
the tissues, anemia leads to hypoxia (lack of oxygen) in organs. Because all human cells
depend on oxygen for survival, varying degrees of anemia can have a wide range of clinical
consequences.
General Objectives:
To provide information and knowledge about the nature of disease and also to comply with
the requirements of the Nursing Care Management 103 of the BSN.
Specific Objectives:
TABLE OF CONTENTS
Anemia 2 Chronic Kidney Disease 2
Hypertensive Nephroschlerosis
Title Page
Acknowledgement i
Introduction.. ii
Objectives. iii
Table of Contents. iv
Patients Personal Data 1
General Assessment.. 2
o Patients Personal Data
o Past Medical History
o Present Medical History
o Familial Tendency
o General Appearance on First Sight
Definition of Terms.. 6
Anatomy and Physiology. 7
Pathophysiology 18
Medical Management.. 19
Laboratory Results.. 21
Drug Study 25
Nursing Care Plans.. 30
Discharge Planning.. 39
Prognosis 42
Anemia 2 Chronic Kidney Disease 2
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PERSONAL DATA
GENERAL ASSESSMENT
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SENSE OF SIGHT
The patient cant identify objects at approximately 3 meters farther, but is
oriented to familiar faces. The patient was observed to be dependent on his
eyeglasses when reading newspapers or any reading materials.
SENSE OF HEARING
Patient has poor hearing competence as observed during the interview. He
cant hear some questions and simple instructions easily even at close distance. He
emphasized that louder voice than normal could help him hear clearly.
SENSE OF SMELL
MR. WBCs sense of smell was not impaired. He can well identify alcohol
from cologne upon assessment. Both nostrils are patent for airway. No obstruction
and discharges were noted.
SENSE OF TASTE
Patients sense of taste was not altered, as verbalized by him. He can identify
and differentiate bitter, sour, salty, and sweet foods.
SENSE OF TOUCH
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The patients skin appears to be pale and relatively dry. His skin was cold and
clammy to touch and has poor skin turgor (4-6 seconds). Uncut nails on fingers and
toes noted. No pertinent scar noted from the face down to arms.
CARDIOVASCULAR
During our span of care his Blood Pressure ranges from 90/70- 130/90
mmHg.The capillary refill time is 3-5 seconds. He has a palpable pounding pulse and
a cardiac rate ranging from 75-89 beats per minute.
RESPIRATORY
During our span of care, patient is experiencing shortness of breath
occasionally as evidenced by even deep respirations with great effort and with a
respiratory rate ranging from 10 - 25 cycles per minute. The doctor ordered O2 as
PRN, no crackles, no rales and no other unusualities was noted.
ELIMINATION PATTERN
As the patient verbalized, he usually urinates 6-8 times a day to a scanty
amount of yellow colored urine, at home. While compared in the hospital, he urinates
three times a day with lighter yellow colored urine as recorded in our 8 hours span of
care. He defecates 1-2 times a day with formed stool at home and defecates once a
day at the hospital.
SLEEPING PATTERN
As the patient verbalized, he tends to have 4-5 hours of sleep a day but having
a nocturnal awakening at some time due to small and frequent urination. Since sleep
patterns also vary on aging process. In the hospital, he experiences difficulty sleeping
due to warm environment and poor ventilation.
EXTREMITIES
Patient range of motion was decreased and altered due to joint pain and
inflammation on both upper (elbows) and lower (knees) extremities. Dry skin noted
Anemia 2 Chronic Kidney Disease 2
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with no lesions. He had even hair distribution on his extremities and pallor on the
upper and lower extremities specifically on his hands, arms and legs. Patient had a
cold clammy skin upon assessment when touched on his hand.
NUTRITIONAL PATTERN
As the patient verbalized, he eats three times a day and he loves to eat meat
and fish (anchovy and anchovy paste; dried fish ), he also eats canned goods for a
quick meal viand. He often drinks liquor three times a week and can consume 1-3
bottles every time he does. Choice s of alcoholic drinks are usually Tanduay, San
Miguel Beer or Red Horse with his kumpadres , as verbalized by the patient. He
often prepares cooked internal organs or fish dipped in vinegar as pulutan.
Upon admission, the patient was ordered on a Low salt, low fat diet and an
increase on oral fluid intake. His mother and wife always brings his meals, usually
vegetable dishes such as dining-ding and soup.
DEFINITION OF TERMS
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Acute uric acid nephropathy - is a rapidly worsening (decreasing) kidney function (renal
insufficiency) that is caused by high levels of uric acid in
the urine (hyperuricosuria).
Albumin - refers generally to any protein that is water soluble, which is moderately soluble
in concentrated salt solutions, and experiences heat coagulation(protein
denaturation). Substances containing albumin, such as egg white, are called
albuminoids.
Anemia - is a decrease in normal number of red blood cells (RBCs) or less than the normal
quantity of hemoglobin in the blood
Creatinine - is a spontaneously formed cyclic derivative of creatine. Creatinine is chiefly
filtered out of the blood by the kidneys (glomerular filtration and proximal
tubular secretion).
Erythropoiesis - is the process by which red blood cells (erythrocytes) are produced. It is
stimulated by decreased O2 delivery to the kidneys, which then secrete the
hormone erythropoietin
Hypertensive nephropathy - (or "hypertensive nephrosclerosis", or "Hypertensive renal
disease") is a medical condition referring to damage to the kidney due to
chronic high blood pressure.
Hyperuricemia - is a level of uric acid in the blood that is abnormally high. In humans, the
upper end of the normal range is 360 mol/L (6 mg/dL) for women and
400 mol/L (6.8 mg/dL) for men.
Purine - is a heterocyclic aromatic organic compound, consisting of apyrimidine ring fused
to an imidazole ring. Purines, including substituted purines and
their tautomers, are the most widely distributed kind of nitrogen-containing
heterocycle in nature.
Blood
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Blood is one of the connective tissues. As a connective tissue, it consists of cells and
cell fragments (formed elements) suspended in an intercellular matrix (plasma). Blood is the
only liquid tissue in the body that measures about 5 liters in the adult human and accounts for
8 percent of the body weight.
The body consists of metabolically active cells that need a continuous supply of
nutrients and oxygen. Metabolic waste products need to be removed from the cells to
maintain a stable cellular environment. Blood is the primary transport medium that is
responsible for meeting these cellular demands.
Blood cells are formed in the bone marrow, the soft, spongy center of bones. New
(immature) blood cells are called blasts. Some blasts stay in the marrow to mature. Some
travel to other parts of the body to mature.
Composition of blood
When a sample of blood is spun in a centrifuge, the cells and cell fragments are
separated from the liquid intercellular matrix. Because the formed elements are heavier than
the liquid matrix, they are packed in the bottom of the tube by the centrifugal force. The light
yellow colored liquid on the top is the plasma, which accounts for about 55 percent of the
blood volume and red blood cells is called the hematocrit, or packed cell volume (PCV). The
white blood cells and platelets form a thin white layer, called the buffy coat, between
plasma and red blood cells.
Plasma
The watery fluid portion of blood (90 percent
water) in which the corpuscular elements are
suspended. It transports nutrients as well as wastes
throughout the body. Various compounds, including
proteins, electrolytes, carbohydrates, minerals, and fats,
are dissolved in it.
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Formed Elements
The formed elements are cells and cell fragments suspended in the plasma. The three
classes of formed elements are the erythrocytes (red blood cells), leukocytes (white blood
cells), and the thrombocytes (platelets).
Thrombocytes (platelets)
Thrombocytes, or platelets, are not complete cells, but are small fragments of very
large cells called megakaryocytes. Megakaryocytes develop from hemocytoblasts in the red
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bone marrow. Thrombocytes become sticky and clump together to form platelet plugs that
close breaks and tears in blood vessels. They also initiate the formation of blood clots.
URINARY SYSTEM
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Our
body is
like a
machine . Machine needs oil or gasoline to work. Our body needs food in order to carry out
its activities. Once the food has reached the body systems, they are quickly used for energy.
In the process, wastes materials are produced which need to be removed from the body. The
solid waste material comes out through the anus, while the fluid material is eliminated
through the urinary system.
Kidneys
The kidneys are two brownish, bean shaped organs about the size of a fist, they weigh
about 5 ounces. They are located in the upper right and left back part of the abdominal cavity.
Each kidney contains about 1,200,000 microscopic filters called nephrons. Nephrons are
smaller than the smaller dots.
The main function or the kidneys are to maintain the water balance and to eliminate
waste materials from the blood.
Ureters
The left and the right ureters are long muscular tubes. They are about 12 inches long
with a diameter 2 to 3 millimeters.
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The ureters connect pelvis of each kidney to urinary bladder. They carry urine from
each kidney to the urinary bladder.
The urinary bladder is a muscular sac that holds urine. It is located in front the pelvis
and behind the pubis. As the bladder fills walls stretch signaling the desire to urinate.
The Urethra
The urethra is a muscular tube which carries urine from the bladder to the outside part
of the body. In the female, it is a one inch long from the bladder to the cleft of the labia. In
the male, it is several inches long from the prostate gland to the penis. When one is about to
urinate, a value in the urethra relaxes to allow the urine to flow out.
Waste Products
During normal activity of the body, waste product are formed. The chief waste of the
body are carbon dioxide, water, urea and salts. Carbon dioxide is eliminated through the
lungs while water, urea and salts are eliminated through the urine. Urea is a product resulting
from the breakdown of protein foods and of protoplasm. It is excreted mainly but the
kidneys.
Glomerulus
Filtered Fluid
The filtered fluid enters the bowmans capsule, where it flow down through its
twisted tubes. The walls of the tubes absorb back in to the blood the needed water and blood
chemicals.
Unwanted chemicals are discharged. The unwanted chemicals are the waste products.
They come out in the form of urine. The urine passes into the ureter and on to the urinary
bladder. And the urethra which releases it to the outside of the body. Urine gives valuable
clues to the body. Sugar in the urine is an indication of diabetes. Albumen may signify that
the kidneys are not functioning properly.
CIRCULATORY SYSTEM
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The human circulatory system. Red indicates oxygenated blood, blue indicates
deoxygenated.
The circulatory system is an organ system that passes nutrients (such asamino
acids and electrolytes), gases, hormones, blood cells, etc. to and fromcells in the body to help
fight diseases and help stabilize body temperature andpH to maintain homeostasis.
This system may be seen strictly as a blood distribution network, but some consider
the circulatory system as composed of the cardiovascular system, which distributes blood,
[1]
and the lymphatic system,[2] which distributeslymph. While humans, as well as
other vertebrates, have a closed cardiovascular system (meaning that the blood never leaves
the network ofarteries, veins and capillaries), some invertebrate groups have an open
cardiovascular system. The most primitive animal phyla lack circulatory systems. The
lymphatic system, on the other hand, is an open system.
Two types of fluids move through the circulatory system: blood and lymph. The
blood, heart, and blood vessels form the cardiovascular system. The lymph, lymph nodes,
and lymph vessels form the lymphatic system. The cardiovascular system and the lymphatic
system collectively make up the circulatory system.
The main components of the human cardiovascular system are the heart and the blood
vessels.[3] It includes: the pulmonary circulation, a "loop" through the lungs where blood is
oxygenated; and the systemic circulation, a "loop" through the rest of the body to
provide oxygenated blood. An average adult contains five to six quarts (roughly 4.7 to 5.7
liters) of blood, which consists of plasma, red blood cells, white blood cells, and platelets.
Also, the digestive system works with the circulatory system to provide the nutrients the
system needs to keep the heart pumping.
Pulmonary circulation
The Pulmonary circulation is the portion of the cardiovascular system which
transports oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated
blood back to the heart.
Oxygen deprived blood from the vena cava enters the right atrium of the heart and flows
through the tricuspid valve into the right ventricle, from which it is pumped through
the pulmonary semilunar valve into the pulmonary arteries which go to the lungs. Pulmonary
veins return the now oxygen-rich blood to the heart, where it enters the left atrium before
flowing through the mitral valve into the left ventricle. Then, oxygen-rich blood from the left
ventricle is pumped out via the aorta, and on to the rest of the body.
Systemic circulation
Systemic circulation is the portion of the cardiovascular system which transports oxygenated
blood away from the heart, to the rest of the body, and returns oxygen-depleted blood back to
the heart. Systemic circulation is, distance-wise, much longer than pulmonary circulation,
transporting blood to every part of the body.
Coronary circulation
The coronary circulatory system provides a blood supply to the heart. As it provides
oxygenated blood to the heart, it is by definition a part of the systemic circulatory system.
Heart
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View from the front, which means the right side of the heart is on the left of the diagram (and
vice-versa)
Main article: heart
The heart pumps oxygenated blood to the body and deoxygenated blood to the lungs. In the
human heart there is one atrium and oneventricle for each circulation, and with both a
systemic and a pulmonary circulation there are four chambers in total: left atrium, left
ventricle, right atrium and right ventricle. The right atrium is the upper chamber of the right
side of the heart. The blood that is returned to the right atrium is deoxygenated (poor in
oxygen) and passed into the right ventricle to be pumped through the pulmonary artery to the
lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly
oxygenated blood from the lungs as well as the pulmonary vein which is passed into the
strong left ventricle to be pumped through the aorta to the different organs of the body.
PATHOPHYSIOLOGY
Monosodium urate
Hyperurecemia
crystal
Blood circulation in
disposition
blood Kidneys
throughout the body
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Joints
Monosodium urate
precipitates at the
periphery of the body
Perfusion in kidneys
Arthritis
Blood flow to
kidneys
Disposition on renal
interstitial tissues
Chronic Kidney
Disease
ANEMIA
If treated: If untreated:
Prevent mental
further function
complication Heart &
s & infection kidney
oxygen in problems
the blood Death
PATHOPHYSIOLOGY
Narrative
With regards to our patients case, the following are the predisposing factors which
contribute to his condition. These include: his age (45 y.o.) and genetic or familial history.
Studies show that aside from hypertension, age is an independent major predictor of chronic
kidney disease. Other than that, precipitating factors also contribute to increase the risks of
Anemia 2 Chronic Kidney Disease 2
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this said condition such as lifestyle, diet high in purines, weight, a long-term alcohol
consumption and medical condition (hypertension).
Since the patients diet is high in purine, these purine- rich foods break down into uric
acid. Uric acid levels in the blood and other parts of the body can become too high or what
we call hyperurecemia. These urate crystals travel all through out the system of our body.
Once it reaches the kidneys, it will accumulate and build up into it. Thus, it alters its function.
There will be a decrease in blood flow and perfusion that mazy lead to Chronic Kidney
Disease. As an attempt to compensate for the loss of renal function, the remaining nephrons
undergo vasodilation of the preglomerular arterioles and experience an increase in renal
blood flow and glomerular filtration. The result is glomerular hypertension. These
mechanisms are not mutuatlly exclusive, and they may operate simultaneously in the
kidneys.
Furthermore, a decrease in the function of the kidneys may also decrease the
production of red blood cells which carries oxygen into the blood (hemoglobin). When it
happens, hypoxia occurs. Then, some signs and symptoms may also be observed in the client
such as pallor, fatigue, poor concentration and dizziness. Thus, all these mechanism may
result to a disease called anemia.
MEDICAL MANAGEMENT
Herceds
LABORATORY
IPD Hematology
CBC + PLT
Hemoglobin 81.0 L(low) 135-175g/ L A low hemoglobin count can also
be caused by an abnormality or
disease. In these situations, a low
hemoglobin count is referred to as
anemia
Hematocrit 0. 24 L(low) 0. 40- 0. 52 A low hematocrit is referred to as
being anemic
RBC Count 3. 02 L(low) 4. 20- 6. 10 x 10^ Anemia is the condition of having
6/uL less than the normal number of red
blood cells or less than the normal
quantity of hemoglobin in the
blood. The oxygen-carrying
capacity of the blood is, therefore,
decreased.
WBC Count 6. 69 5.0- 10. 0 x 10^ 3/uL No infection.
Differential
Count
Neutrophil 64 55- 75%
Lymphocytes 19 L(low) 20- 35% Lymphocytes help protect your
body from infection. Low numbers
of lymphocytes can increase your
risk for infection.
Borderline for impending infection.
Monocytes 9 2- 10%
Eosinophils 8 1- 6%
Basophils 0 0- 1%
Platelet Count 466 H 150- 400x 10^ 3/uL May have a tendency to bleed due
to the lack of stickiness of the
platelets; in others, the platelets
retain their stickiness but, because
they are increased in number, tend
to stick to each other, forming
clumps that can block a blood
vessel and cause damage, including
death (thromboembolism).
MCH 26. 8 25. 70- 32. 20pg
MCHC 33. 6 32. 30- 36. 50g/ dL
ER
Glucose- RBS 5.5 3. 90- 6. 10
Creatinine 299. 30 53.00- 115.00 mmol/ Increased creatinine levels in the
L (High) blood suggest diseases or
conditions that affect kidney
function.
Sodium 138. 00 136- 155.00 mmol/ L
Potassium 4.4 3.5- 5.5 mmol/ L
Uric Acid 0. 85 0.24- 0.42 mmol/ L Increased concentrations of uric
(High) acid can cause crystals to form in
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BLOOD TYPING
Abelo
Physician
Spermatozoa
ROENTOLOGICAL REPORT
Name: WBC Dept: Internal Medicine Area: Charity Ward Date: 2/6/10
Age: 45 Yrs. Old Sex: Male
Chest PA (ADULT)
Findings:
The lungs are clear. Tracheal air column are at the midline. The heart is not enlarged. Both
hemidiaphragms and costophrenic sulci are intact. The rest of the structures are unremarkable.
Squamous
Renal
Pus Cells 6-10 / hpf
RBC 0-2 / hpf
Mucus Threads
Bacteria
Yeast Cells
Oil Globules
Spermatozoa
ULTRASOUND
Name: WBC Age: 45 Yrs. Old Sex: Male Date: 2/10/10
RESULT FINDINGS
Length Width Thickness(cm) Cortical Thickness (cm)
Right Kidney 9.56 4.31 5.33 1.41
Left Kidney 10.50 4.39 4.63 1.54
Impressions/ Remark
Bilateral Nephroschlerosis
Sonographically Normal Urinary Bladder
Earnest L. Pedregosa, MD Maria Theresa Sanchez, MD
Medical Officer IV Medical Officer IV
PROGNOSIS
Computation:
Prognosis
Formula=_______________X 100
Criteria
Solution:
a.) POOR b.) GOOD
4 3
= --- X 100 = --- X 100
7 7
= 0.5714 x 100 = 0.4285
= 57.1428 = 42.8571
SUMMARY
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The general prognosis of our patient is poor as shown in the table above. Considering that
there are several significant factors contributing to his illness. Prompt identification of factors
affecting high risk requires prompt intervention in order to enhance clients quality of life.
DISCHARGE PLANNING
Medications
Motivate the patient and initiate family members to always seek medical advise.
: This facilitates their understanding towards health and wont rely to other medicines
that could not help the status of the patient.
Explain environmental factors that may worsen his condition and discuss possible
precipitating factors
: This prevents recurrence or exacerbation of the patients condition.
Stress management.
: Stress management can be considered a cornerstone to a healthy lifestyle.
Treatment
Outpatient Orders
Instruct the patient to take all the prescribed take home medications religiously.
: To facilitate faster recovery, prevent further complications, and alleviate pain.
Diet
Encourage patient to reduce eating fatty and salty foods and foods high in uric acid.
: Low salt and low fat diet is needed for faster recovery.
: To prevent dehydration.
BIBLIOGRAPHY
2. Gulanick & Myers Nursing Care Plans Nursing Diagnosis and Interventions; 6 th
Edition
3. Barbara E. Goulds Pathophysiology for the Health Professions; 3rd Edition; Pages
279-289
5. Lippincott, Williams & Wilkins Nursing 2006 DRUG Handbook; 26th Edition
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7. Judith Hopfer Deglin & April Hazard Vallerands Daviss Drug Guide for Nurses,
10th Edition
Websites:
1. www.yahoo.com
2. www.google.com
3. www.nursingcrib.com