I.

OBECTIVES OF CASE STUDY

The main purpose of this case presentation is to help healthcare professionals, especially nurses, to
understand the causes of and the current treatments and nursing interventions for Pulmonary
Congestion, Chronic Kidney Disease secondary to DM.
Specifically, this presentation aims to:
Discuss comprehensive study of the case
Define the demographics and risk profile of this disease.
Analyze the most important factors affecting the prognosis of the patients with SCC of the tongue.
Relate laboratory results with the manifestation of the disease.
Know the pathophysiology of the disease and to be able to relate signs and symptoms to the disease
process
Be acquainted with the nursing interventions applicable to the patient.
Understand the importance of medical and surgical management done to the patient.
Formulate plans unique to the patient for the continuity of patient care.
II. Introduction
Chronic Kidney Disease is a progressive and irreversible damage of the functioning unit of the
kidneys, the nephrons. It is a progressive loss in renal function over a period of months or years.
The symptoms of worsening kidney function are non-specific 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 kidney problems, such as
those with high blood pressure or diabetes and those with a blood relative with chronic kidney
disease.
Chronic kidney disease may also be identified when it leads to one of its recognized
complication, such as cardiovascular disease, anemia or pericarditis. It is differentiated from
acute kidney disease in that the reduction in kidney function must be present for over 3 months.
It is identified by a blood test for creatinine. Higher levels of creatinine indicate a lower
glomerular filtration rate and as a result a decreased capability of the kidneys to excrete waste
products. As renal function deteriorates, nitrogen containing waste products accumulate in the
blood and the uremic syndrome develops. Uremic syndrome is the cluster of clinical findings
associated with the build-up of nitrogen containing in the blood, which may include fatigue
diminished mental alertness, agitation, muscle twitches, cramps, anorexia, nausea, vomiting,
inflammation of the membranes of the mouth, itchy skin, skin hemorrhages, gastritis, GI
bleeding and diarrhea. Classification / Types Renal failure can be acute or chronic. In acute
renal failure, the nephrons suddenly lose function and are unable to maintain homeostasis. On
the other hand, chronic renal failure, the GFR drops suddenly and sharply. The GFR deteriorates
and renal function is irreversibly altered. Chronic renal disease results from irreversible loss of
large numbers of functioning nephrons. It can be categorized into five stages. The first stage is
when the kidney is damaged with GFR>90 mL/min. Second stage is when GFR reaches down
to 60 to 89 mL/min. In the third stage, GFR falls to 30-59 mL/min. In the fourth stage, the
kidney damage is severe and the GFR is already too low reaching 15-29 mL/min. Finally in the

fifth stage, the GFR already falls below 15 mL/min. In this stage, dialysis or kidney
replacement is essential for the survival of the patient.

III. Epidemiology
Globally, Chronic kidney disease (CKD) is a key determinant of the poor health outcomes for major
NCDs. CKD is a worldwide threat to public health, but the size of the problem is probably not
fully appreciated. Estimates of the global burden of the diseases report that diseases of the
kidney and urinary tract contribute with 830 000 deaths annually and 18 867 000 disability-adjusted
life years (DALY), making them the 12th highest cause of death (1.4% of all deaths) and the 17th
cause of disability (1% of all DALY). This ranking is similar across world Bank regions, but,
among developing areas, East Asia and Pacific regions have the highest annual rate of
death due to diseases of the genitourinary system. National and international renal registries offer an important
source of information on several aspects of CKD. In particular, they are useful in characterizing the population
on renal replacement therapy (RRT) due to end-stage renal disease (ESRD), describing the
prevalence and incidence of ESRD and trends in mortality and disease rates. According to this
analysis, the most recent available data indicate that the prevalence of ESRD ranges from 2447 pmp
in Taiwan to 10 pmp in Nigeria. However, there is paucity of renal registries glob ally
with an international standard for registry data collection, especially in low- and middle-income
countries,where, in addition, the use of RRT is scarce or non-existent, eventually making it difficultto compare
ESRD results.
Nationally, Manila,, Philippines In 2003, the Department of Health reported that the prevalence of chronic
kidney disease (CKD) among adult =Filipinos was 2.6 percent(or 2.6 out of 100 adult
Filipinos). Recent research suggests that CKD prevalence ha wo r s e n e d , a f f e c t i n g o n e i n
1 0 a d u l t F i l i p i n o s . I n 2 0 1 4 , t h e N a t i o n a l K i d n e y a n d Transplant Institute
cited kidney failure as the ninth leading cause of death among Filipinos. Consistent
with worldwide statistics, the Philippine Renal Registry reports thatdiabetes is the leading cause
of CKD at 44.6 percent, with hypertension as the runner-up at 4/ percent. Early detection and
treatment can often keep chronic kidney from getting worsen.
IV. Patient data and Health history
A. Demographic
Name of patient: mr. X
Age: 67 y/o
Sex: male
Civil status: married
Educational attainment:college grauduate
Occupation: retired
Religion: roman catholic
Birthday: may 27, 1947
Nationality: Filipino
B. Chief Complaints : Difficulty of Breathing
Initial Diagnosis : Pulmonary Congestion

Diagnosis: Pulmonary Congestion CKD secondary to DM

Date of admission :
May 25, 2015
Attending physician : DR. B
Informant : Wife
C. 1. HISTORY oF Past and Present Illness

Px is 67y/o male, previously smoker and drink occassionally

Hypertension 20years, ubp 11/70, hbp 130/70

type 2 DM 20 years

COPD, last attack Feb 2015, s/p intubation

CAD s/p Angioplasty 2-3 stents (feb 2014) heart center

Hemmorhagic cystitis -Feb 2015

CKD secondary to DM on MHD every MthS x 2 years

ARF secondary to CAP MR

1 week prior to admission patient complained of productive cough able to

expectorate phlegm, no fever, chills noted, no medications taken.
C. 2 History of Present Illness

Day of admission px complained of undocumented fever accompannied with

difficulty of breathing, sought consult to tayta doctors, CXR shows
pnuemonia. Px also underwent scheduled of HD UF 5.5 Liters with minimal
relief advised admission but opted to tranfer to TMC

Hypertension 20years, ubp 11/70, hbp 130/70

type 2 DM 20 years

COPD, last attack Feb 2015, s/p intubation

CAD s/p Angioplasty 2-3 stents (feb 2014) heart center

Hemmorhagic cystitis -Feb 2015

CKD secondary to DM on MHD every MthS x 2 years

ARF secondary to CAP MR

D. Family History

His father had hypertension, and his mother had DM.

E. Review of Current Medications

Seretide inhaler 125mcg 1 puff 2x a day

Ventolin nebule as needed
Captopril 25mg tab 2x a day

Lanoxin tab MWF

Carvedilol 6.25mg tab once a day
Clopidogrel 75mg/tab once a day
Vestar 25mg 2x a day

F. Allergies
Allergy to Seafoods
V. Physical assessment

VI. Anatomy and physiology

The kidneys are a pair of bean-shaped organs that lie on either side of the spine in the lower middle of
the back. Each kidney weighs about 5 ounces and contains approximately one million filtering units
called nephrons. Each nephron is made of a glomerulus and a tubule. The glomerulus is a miniature
filtering or sieving device while the tubule is a tiny tube like structure attached to the glomerulus.
The kidneys are connected to the urinary bladder by tubes called ureters. Urine is stored in the urinary
bladder until the bladder is emptied by urinating. The bladder is connected to the outside of the body by
another tube like structure called the urethra.

Illustration of the kidneys, urinary tract, and bladder.

The main function of the kidneys is to remove waste products and excess water from the blood. The
kidneys process about 200 liters of blood every day and produce about 2 liters of urine. The waste
products are generated from normal metabolic processes including the breakdown of active tissues,
ingested foods, and other substances. The kidneys allow consumption of a variety of foods, drugs,
vitamins and supplements, additives, and excess fluids without worry that toxic by-products will build
up to harmful levels. The kidney also plays a major role in regulating levels of various minerals such as
calcium, sodium, and potassium in the blood.

As the first step in filtration, blood is delivered into the glomeruli by microscopic leaky blood
vessels called capillaries. Here, blood is filtered of waste products and fluid while red blood
cells, proteins, and large molecules are retained in the capillaries. In addition to wastes, some
useful substances are also filtered out. The filtrate collects in a sac called Bowman's capsule.

The tubules are the next step in the filtration process. The tubules are lined with highly
functional cells which process the filtrate, reabsorbing water and chemicals useful to the body
while secreting some additional waste products into the tubule.

The kidneys also produce certain hormones that have important functions in the body, including the
following:

Active form of vitamin D (calcitriol or 1,25 dihydroxy-vitamin D), which regulates absorption
of calcium and phosphorus from foods, promoting formation of strong bone.

Erythropoietin (EPO), which stimulates the bone marrow to produce red blood cells.

Renin, which regulates blood volume and blood pressure. Chronic kidney disease occurs when one
suffers from gradual and usually permanent loss of kidney function over time. This happens gradually,
usually over months to years. Chronic kidney disease is divided into five stages of increasing severity
(see Table 1 below). The term "renal" refers to the kidney, so another name for kidney failure is "renal
failure." Mild kidney disease is often called renal insufficiency.
With loss of kidney function, there is an accumulation of water, waste, and toxic substances in the body
that are normally excreted by the kidney. Loss of kidney function also causes other problems such as
anemia, high blood pressure, acidosis (excessive acidity of body fluids), disorders of cholesterol and
fatty acids, and bone disease.
Stage 5 chronic kidney disease is also referred to as kidney failure, end-stage kidney disease, or endstage renal disease, wherein there is total or near-total loss of kidney function. There is dangerous
accumulation of water, waste, and toxic substances, and most individuals in this stage of kidney disease
need dialysis or transplantation to stay alive.
Unlike chronic kidney disease, acute kidney failure develops rapidly, over days or weeks.

Acute kidney failure usually develops in response to a disorder that directly affects the kidney,
its blood supply, or urine flow from it.

Acute kidney failure is often reversible, with complete recovery of kidney function.

Some patients are left with residual damage and can have a progressive decline in kidney
function in the future.

Others may develop irreversible kidney failure after an acute injury and remain dialysisdependent.
Table 1. Stages of Chronic Kidney Disease

GFR*
mL/min/1.73 m2
*GFR is glomerular filtration rate, a measure of the kidney's function.
1
Slight kidney damage with normal or increased filtration More than 90
2
Mild decrease in kidney function
60 to 89
3
Moderate decrease in kidney function
30 to 59
4
Severe decrease in kidney function
15 to 29
5
Kidney failure
Less than 15 (or dialysis)
Stage

Description

VII.

Pathophysiology

VIII.

Course in the ward

May 25, 2015

6:20pm
Admitted patient at er with gcs 15/15, bp 118/58 hr 56 rr 28 o2 sats 96%
(+) crackles bilateral, pt. Given isoket drip increase to 15ml/hr, continous bp
monitoring. Standby intubation if with progression of symptoms (drowziness or
desaturation).
7:06
(+) drowsy, BP 105/49, O2 Sats 89%. Decrease isoket drip to 10ml/hr, Px is
for stat intubation (consent secured), Given MidaZolam 5mg/iv, and Fentanyl
25mg/iv.
7:40pm
(+) drows, tachypneic , (+) crackles, BP 113/57, HR 44,
D/C isoket drip, Px is intubated w/ ET 7.5 at 22 level (+) yellowish thick
secretions.
CXR -AP done
ABG 1hr post intubation
insert NGT
fastdrip 200cc IV of PNSS
Calcium Gluconate 1 amp slow iv push
7:58pm
Trop I 211.6
BP 68/38, HR 47
Fast drip another 300ml of PNSS
8:40pm
BP 86/47 HR 40
Started Levophed Drip (Levophed 16mg in 250ml PNSS to start at 10ugtts/hr
px was admitted under dr B, refer to dr p for nephro, dr v for cardio,
labs and diagnostics facilitated : cbc, na, k, ica mg ETA GS/CS, Blood CS x 2,
pt, aptt, abg,
CXR-AP, 12 L ecg , heplock noted at right arm
Meds : Duavent neb every 6hours, Piperracillin Taobactam 2.25g/iv every
8hours,
CBG monitoring every 4 hours
9:15
admitted at the icu
Started feeding of 1500 kcal nephro based DM continous feeding at
62.5ml/hr + 30ml water
flushing every 8hours
Head of bed 30-45
decreased FIO2 to 60%
2d echo defer (relative)
Hold Carvedilol, Lanoxin and Captopril for now
start Fluimucil 600mg/tab 1 ta in glass of water 2x aday/ngt

apply 2 point restraints

if with agitation pls start precedex dip for sedation
include serum cortisol, uric acid to bloodworks
rpt cbc and serum k tom post bt
CBG 3x a day
hold insulin for now
Pt is for HD on thurs (may 28)
9:26pm
ph 7.423, pc02 37.8, P02 291.1, Bicarb 24.9, 02 Sats 99..9% - decreased
FIO2 to 40%
May 26, 2015
1:15am
Px cough out the ET tube, Monitored patient, On standy by re-entubation.
Px re-intubated, midazolam 1mg/iv given for pre medications
1:55am
requested for CXR to confirm ET is on top of location
Started midazolam drip 30mg in 30ml of D5W to start at 1mg/hr ( hold if
with hypotension)
7:00am
for sled on thursday
give piperacillin tazobactam of 0.75mh/iv after HD
Started Esomeprazole 40mg/iv now then once daily
nebulize with salbutamol every 8hours
start enoxaparin 0.2ml once daily
8:00am
still with Low blood pressure and bradycardia
titrated levophed
given albumin 20% 1vial + 200ml PLR bolus, but still no improvement
recommend dopamine instead of norephineprine
continue duavent neb every 6hours hold salbutamol
11:15
Started dopamine drip 20ml in 250ml PNSS in 2mg/kg/min and titrate to
target MAP of >70.
Re Scheduled pt. dialysis tom and friday 8 hours,
transfuse 2units PRBC during dialysis, properly typed and crossmatched
4:00pm
maintained MV settings
Give Vancomycin 1g in 100ml PNSS to sun for 2 hours

7:00pm
Started Lactulose 30ml once a day at bbedtime
shift esomeprazole to Pantoprazole 40mg/iv
increase midaolam to 1.5ml/hr
apply 2 point restrants
May 27 2015
Changed MV setting to FIO@ 35, PS 12
for cxr ap sitting after HD
decreased duavent neb to every 8hours
Start Vancomycin 500mg every @ days diluted in 100 ml PNSS to run for 1
hour,,
on dialysis days give vancomycin 2grams diluted in 200ml PNSS at
15mg/min over the last 2
hours of dialysis
facilitate BT
continue piperacillin tazobactam
Budesonide 500mcg 1 nebule every 12hours
titrate dopamine drip to Map >65
for cbc tom include na, k , mg
Shifted vancomycin to oxacillin 2grams every 6hours
May 28, 2015
For HD tomorrow (friday), 8hours duration
for 2d echo with DS done
Done ABG
Maintianed MV settings, and o2 sats >94%, for passive leg raise
Start Lactulose 30 ml once daily- hold if with BM 2x a day
shifted pantopraole to lansopraole 30mg/tab once a day per ngt
revise feeding to 1500kcal nephro baased DM 2:1dilution with 20ml flushing
every 4 hours
increased duavent neb to every 6hours
continue suctions thick secretions
maintained present vent setting for now
for abg, lactate tom morning and include cortisol, and phospuros
May 29, 2015
please apply 2 point restraints
for repeat CXR post HD
for rpeat cbc pre HD
please reserve 1u PRBC properly typed and crossmatched for possible
transfusion during HD
Start Hydrocortisone 200mg/iv in 200ml PNSS for 24hours
Facilitate HD
decreased PS to 10

decreased duavent neb to every 8hours and as needed

continue oxacillin and piperacillin taobactam,

IX. Drug study

X. Diagnostic exams and results
XI. Nursing care plan
PROBLEM

GOAL OF CARE

INTERVENTION

EVALUATION

INEFFECTIVE
AIRWAY
CLEARANCE
RELATED TO (+)
YELLOW THICK
SECRETION

After 8 hours, the

patient will have no
signs of respiratory
distress and
desaturation, and
maintain airway
patency.

Assess respiratory rate

and secretions

After 8 hours, the

patient noted no signs
of respiratory distress
and desaturation, and
airway patency
maintained.

Objective:
-yellowish thick
secretion
-crackles at bilateral
lower segment
-with Endotracheal tube
with closed suction

Auscultate bilateral
lower segment of the
lungs
Elevate head of bed
Turn patient side to side
every 2 hours
Suction secretion as
needed
Administer mucolytics
as prescribed
Perform nebulization as
ordered
Perform
chestphysiotherapy
(back tapping)

PROBLEM

GOAL OF CARE

INTERVENTION

EVALUATION

FLUID VOLUME
EXCESS RELATED
TO PULMONARY
CONGESTION

After 8 hours, patient

will have no signs of
respiratory distress and
desaturation, and
maintain airway
patency.

Assess respiratory rate

and secretions

After 8 hours, the

patient noted no signs
of respiratory distress
and desaturation, and
airway patency
maintained.

Objective:
-crackles at bilateral
lower segment
- (+) agitation
(+) drows,
tachypneic ,
Shortness of
breath
BP-111/58
HR 56
RR 28
o2 sats 96%
XII.

Discharge planning

Auscultate bilateral
lower segment of the
lungs
Elevate head of bed
Turn patient side to side
every 2 hours
Monitor input and
output accurately