B.

Introduction

Chronic kidney disease (CKD) is a serious public health problem

characterized by progressive kidney function loss leading to end-stage

renal disease (ESRD) that demands dialysis or kidney transplantation.

Early detection can prevent or delay progression to ESRD. The most

typical reasons for developing CKD are diabetes mellitus and

hypertension, whereas less common reasons include glomerulonephritis

and polycystic kidney disease. Progression of CKD to ESRD is associated

with the accumulation of metabolites, toxic substances and uremic solutes

in the plasma. (Zhao, 2013).

The significance of this case study is to monitor disease and

treatment consequences, prevent disease progression, and enhance the

patient's physical and psychological well-being. Kidney illness increases

the likelihood of having heart and blood vessel disease, which can strike

suddenly because they are essential to many bodily processes. Kidney

failure can result from kidney disease. The patient's chances of receiving

therapy are better the earlier we are aware that they have the disease.

Because CKD can lead to a number of issues, including fluid overload,

electrolyte imbalances, and anemia that require treatment, prospective

nurses are in a unique position to evaluate their level of knowledge of

CKD, causes, risk factors, and therapy.

Approximately 37 million individuals in the United States have

chronic kidney disease (CKD), and according to the Chronic Kidney

Disease Surveillance System, only half of adults who are at high risk of
kidney failure are aware they have the condition. CKD is a complex

condition, and adults living with it are at increased risk of poor

outcomes, including cardiovascular disease (CVD), end-stage renal

disease (ESRD), hospitalization, and death. According to Centers of

Disease Control and Prevention (2022), Although 15% of adults in the

USA are estimated to have CKD, up to 90% do not know they have CKD,

and even 40% of those with severe CKD do not know they have CKD

Additionally, Chu CD, Chen MH, McCulloch CE et al. (2021), stated that

with most studies reporting <50% of individuals with CKD being aware of

their condition. Despite some evidence of benefits from patient awareness

of CKD (Wright et.al), a growing number of studies have failed to

demonstrate associations between baseline CKD awareness and healthy

behaviors [e.g. avoidance of nonsteroidal anti-inflammatory drugs

(NSAIDs)], ACEi/ARB use, blood pressure (BP) control, glycemic control,

or changes in eGFR and albuminuria (Tuot et. al, 2013).

According to the latest World Health Organization data published in

2020, the Kidney Disease Death rate in the Philippines reached 51.96% or

5.84% of the total deaths. CKD management in the Philippines is an

important issue yet is limited by a paucity of published data on CKD. The

Philippine Renal Disease Registry, with most recent data from 2016, for

example, predominantly reports RRT data, underscoring the rising number

of patients receiving dialysis but not including data on patients with CKD

stages 1 to 4 (Philippine Renal Disease Registry, 2020). According to the

Philippine Renal Disease Registry 2020 Annual report, in 2016, the

incidence and prevalence of patients undergoing dialysis for ESRD in the

Philippines was 21,535 and 37,280, respectively. By 2025, the number of

patients with ESRD in the Philippines is expected to increase by 10–

20%.26 (Sahay et. al 2021). According to a 2019 report, PhilHealth (a

national health insurance program) spent over 10.6 billion Philippine

pesos for 2,187,846 haemodialysis

claims, which ranked first among the top 10 medical procedures.27 These

data underscore the incredible burden of RRT and the need for treatments

that can mitigate CKD progression, which could help offset the high costs

of RRT (Stats and Charts 2019).

In the article published by by Lea Regina Dulay, Lourhenz Igloria,

Rojean Grace Patumbon, and Joana Mae Villanueva, who were UM

Interns, entitled “Alarming times'', Davao City ranked third nationwide with

the most prevalent cases of kidney diseases, a position it has not

relinquished since 2017. Presently, SPMC has a total of 2,400 patients on

dialysis. Doctors are flooded with appointments as they see three to five

patients daily. In a month, they see more or less 60, which rises to 100 if

counting the other hospitals. (Dulay et. Al 2023).

In this module, a 55-year-old man named Marcos was transported

to the emergency room with deep, fast, shallow breathing as well as

bewilderment and mental insanity. His wife stated that because to COVID,

Marcos was unable to undergo dialysis and that he had abruptly swollen,

disliked lying down, and lost the ability to wear his wedding band. During

the evaluation, a bipedal edema grade of 4+ is also recorded. When

Marcos is questioned, he does respond, but he gives evasive responses

and is also difficult to understand, restless, and anxious. Apart from his

blood pressure, heart rate, respiration rate, and oxygen saturation, which

all show unstable values of 180/100 mmHg, 118 cpm, 39 cpm, and 89%,

Marcos' body temperature, which is 37.5, is the only stable vital sign. He
constantly smoked 10 sticks per day for 25 years and drank three times

each week for nine years.

C. Patient’s Profile

i. Biographic Data:

Name: Patient X

Age: 55 yrs old

Gender: M

Birthdate: January 22, 1966

ii. Clinical Data:

Chief Complaint: Manifested deep, rapid, shallow breathing,

mental delirium and confused.

Date of Admission: September 12, 2023

Time of Admission: 8:00 AM

Hospital: Davao Doctors Hospital

Room and Bed No. : 143

Attending Physician: Dr. Beng Gow

iii. Vital Signs Upon Admission:

BP: 180/100 mmHg

RR: 39 cpm

PR: 108 bpm

Temp: 37.5
O2 Sat: 89%

NVS: 11/15
 i. Past Health History

Patient X, 55 years old male born on January 22, 1966. He is

a government employee, 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 with DM type 2 and never did any

form of exercise instead his vices worsened after he retired.

ii. Present Health History

Patient X has been rushed to the emergency department

who manifested deep, rapid, shallow breathing mental delirium and

confused. While doing his assessment the wife suddenly cut off by

saying “Natingala ko ana niya sir na ning kalit raman siyag

kahupong. Dili ganahan muhigda kay punga na daw kaayo. Ang

iyahang singsing guot na. Ang iyahang medyas og sapatos dili na

kasigo. Wala man pod mi kapadialysis sa iyaha sir dapat 2x a week

sya idialysis, mga 2 weeks ago na kay tungod lagi aning ron Covid

lagi si, 6 months ago na siya gisugdan sa iyang dialysis, naa man

sa iyang left nga kamot iyang fistula (AVF) diha man ginaagi sir

pagginadialysis na sya. Mamatay na ba siya ana sir?”

Upon further assessment, you can see the presence of

bipedal edema grade 4+. The daughter of the patient arrived and

said “Dali rana siya kapoyon,

Sir. Dili na niya kaya maglakaw og dugay. Basta maglakaw na siya kay pungahon na siyag samot

maong ning hangyo kog wheelchair ganina para niya.” The patient cannot talk well and is
incomprehensible, restless, and agitated- he did not even recognize his daughter. 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.

iii. Family History

Patient X father 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.

iv. Genogram

D. Health Assessment

This part of the manuscript is dedicated to helping with important

nursing responsibilities that provide the foundation for quality nursing care

and intervention. A health assessment helps in identifying and gathering

the typical risk factors and any changes or health issues that may have an

impact on the patient's condition

General Survey
 Patient M, a 55-year-old male, who stands 5 feet and 8 inches in

height and weighs 90 kg has been rushed to the emergency department

who manifested deep, rapid shallow breathing, mental delirium and

confusion.

Clinical Measurements (Upon Admission)

RESULTS INTERPRETATION

Blood Pressure 180/100 mmHg Hypertension

Temperature 37.5 Normal

Pulse Rate 108 bpm Tachycardia

Respiratory Rate 39 cpm Tachypnea

O2 Saturation 89% Low blood oxygen level

Upon assessing the patient, the findings were as follows:

A. SKIN

Patient entire face and body is having uremic. The nail beds and
palms are very pale.

B. HEAD, EYES, and THROAT

Upon inspection of the head, the patient’s hair is coarse and blowsy.
Eyes are swollen and puffy. Nasal flaring is evident. While the tympanic
membrane is clear, canals clear bilaterally. Oropharynx pink and moist; (-)
erythema, tonsillar enlargement, lesions, teeth erosion; normal size of
thyroid.
C. RESPIRATORY

Patient’s respiratory rate is 39 cpm. Upon auscultation, rales and

crackles were heard.

D. GASTROINTESTINAL

Abdominal girth is 48 inches. Presence of abdominal distention with

spider web like appearance was noted.

E. URINARY

Decrease urine output: 200 cc in 24 hours.

F. PERIPHERAL/VASCULAR

(+) presence of bipedal edema grade 4+ was noted.

G. NEUROLOGIC

The nurse tried to interview the patient but with vague responses,
cannot talk well and is incomprehensible, restless and agitated - he did not
even recognize his daughter.

E. Review of Anatomy & Physiology of the Affected Organ/System

The Urinary system removes waste products by filtering and cleansing

the blood as it passes through the kidneys.The control of blood, lymph,

and other bodily fluid volume, acidity, salinity, concentration, and chemical

composition is another crucial function. The kidneys constantly check the

substances they release into the urine under hormonal regulation in order

to preserve a balanced chemical composition.

A pair of kidneys, two
ureters, a

bladder, and a
urethra make up

the urinary system.

Together, these

parts enable the

urinary system to

perform its three main

tasks:

controlling the amount

and makeup

of bodily fluids, eliminating waste

from the blood, and emptying waste

and extra water from the body in the

form of urine.
The two kidneys are two round, bean-shaped, crimson organs that are

located on either side of the belly, right above the waist, and farther back

on the body. The kidneys have tiny

filtering organs that turn waste,

undesirable

minerals, and extra water from the

blood into

urine. The ureter, a protracted tube

that carries

urine away, connects each kidney to

the bladder.

Central to the pelvis lies the

bladder, a hollow,

muscular organ. Urine is held there until a

favorable time to discharge it. Stretch receptors

in its wall convey nerve signals that cause a

 conscious urge to urinate at a particular volume.

Following that, the urethra transports pee from the bladder to the

outside.

The kidneys sit at the back of the abdominal wall and at the start of the

urinary system. These organs are constantly at work:

➔ Nephrons, tiny structures in the renal pyramids, filter gallons

of blood each day. ➔ The kidneys reabsorb vital substances,

remove unwanted ones, and return the filtered blood back to the body.

As if they weren’t busy enough, the kidneys also create urine to

remove all the waste.

The kidneys are referred to as retroperitoneal organs because of their

position behind the peritoneum. Between the levels of the T12 and L03

vertebrae, they are located at the rear of the abdomen. The right kidney is

positioned a little lower than the left. allow for the liver. The size of an adult

fist and shaped like beans describe both kidneys.

Renal arteries provide
access to the

kidneys for blood. These

arteries

divide into microscopic

capillaries, or

nephrons, which
communicate with

urine organs within the

kidneys. The

blood is filtered here. Vital

components

are reabsorbed into the circulation

while waste is eliminated. The renal

veins are the exit points for the filtered

blood. Every day, the kidneys pump

the entire body's blood hundreds of times in and out, requiring 200 quarts

of liquid to be filtered.

More than 1 million little units known as nephrons are found inside each

kidney. The renal pyramids, where the nephron tubules make up the

majority of the pyramid mass, and the cortex, where the nephrons are

found, are both home to the nephrons. Nephrons carry out the kidneys'

main task, which is to control the body's water and other material

concentrations.

After blood enters a nephron, it goes into the renal corpuscle, also called

a Malpighian body. The renal corpuscle contains two additional structures:

 ➔ The glomerulus.
This is a cluster

of capillaries that
absorb protein

from blood
traveling through
the

renal corpuscle.

➔ The Bowman
capsule. The

remaining fluid,
called capsular

urine, passes
through the
Bowman

capsule into the renal tubules.

The renal tubules are a series of tubes

that begin after the Bowman capsule and end at collecting ducts. Each

tubule has several parts:

➔ Proximal convoluted tubule. This section absorbs water, sodium,

and glucose back into the blood.

➔ Loop of Henle. This section further absorbs potassium, chloride,

and sodium into the blood.

➔ Distal convoluted tubule. This section absorbs more sodium into

the blood and takes in potassium and acid.

When the fluid finally exits the tubule, it has become diluted and is filled

with urea. Urine contains urea, a result of protein metabolism. The

kidney's exterior is called the renal cortex. Along with convoluted tubules,
it has a glomerulus. A layer of fatty tissue called the renal capsule

encircles the renal cortex on all sides. The interior components of the

kidney are housed and safeguarded by the renal cortex and capsule

together. The kidney's smooth inside is called the renal medulla. Henle

loops and renal pyramids are both present.

The nephron and tubule threads seen in renal pyramids are compact

structures. Fluid is delivered into the kidney by means of these tubules.

The fluid then flows away from the nephrons and toward the internal

organs that store and carry urine out of the kidney. In the renal medulla,

every nephron has a collecting duct at its end. The filtered water leaves

the nephrons at this point. The fluid travels from the collecting duct to the

renal pelvis, where it makes its last destination.

The deepest portion of the kidney has a funnel-shaped area called the

renal pelvis. It serves as a passageway for fluid moving toward the

bladder. The calyces are located in the renal pelvis' initial segment.

These are tiny, cup-shaped cavities that hold liquid before it enters the

bladder. Also at this point, excess fluid and waste are converted to urine.

The kidney has a tiny aperture called the hilum that curls inward to give it

its distinctive bean

like shape. It is situated on the inner border of the kidney. The renal pelvis

passes through it, as well as the:

➔ Renal artery. This brings oxygenated blood from the heart to the

kidney for filtration.

➔ Renal vein. This carries filtered blood from the kidneys back to the heart.
 Urine Formation

One of the body's waste products is

urine. It is mostly

made up of urea and water. The body is

required to

regularly eliminate urea, a particular

nitrogenous waste

product. Glomerular filtration,

reabsorption, and

secretion are the three steps of urine production in the

kidney.
Stage 1: Filtration

Each kidney has more than 1 million nephrons, which are very small

structures. A glomerulus, which is where blood is filtered, is present in

each nephron. As blood passes through the glomerulus, blood pressure

forces water and solutes from the capillaries into the capsule via a filtering

membrane. Glomerular filtration is the first step in the generation of urine.

A unique layer of cells within the glomerulus allows blood pressure to drive

fluid from capillaries into the glomerular capsule. Blood cells and large

proteins cannot flow through the filtration barrier, but water and small

solutes may. The bloodstream retains these chemicals. The filtrate travels

from the glomerular capsule farther into the nephron.

Stage 2: Reabsorption

The glomerulus removes tiny solutes and water from the circulation. The

resultant filtrate includes trash as well as nutrients the body need,

including glucose, amino acids, and smaller proteins. The renal tubule is a

conduit in the nephron where the filtrate travels after leaving the

glomerulus. The required materials, along with some water, are

reabsorbed through the tube wall into nearby capillaries as it travels. Urine

is produced in two steps, the second of which is the reabsorption of

essential elements from the filtrate.

Stage 3: Secretion

The renal tubule receives the glomerular filtrate and reabsorbs nutrients

and water into capillaries there. Hydrogen and waste ions both enter the

renal tubule from the capillaries at the same time. This process is referred

to as secretion. Urine is created when the released ions combine with the

leftover filtrate. The collecting duct is where urine enters

after leaving the nephron tubule. It leaves the kidney through the renal

pelvis, travels through the ureter, and eventually emerges from the

bladder.
 Pathophysiology

i. Definition of Diagnosis

Chronic Kidney Disease (CKD) is a condition wherein there is a gradual

significant decrease in the kidney's normal function over a long period of

time. CKD is when the kidney's glomerulus loses its filtrating function

progressively which can significantly affect the homeostasis of the body.

The kidneys are responsible for filtering wastes from the blood and are

responsible for reabsorbing water and other electrolytes and excreting

harmful toxins and waste products such as creatinine and urea. However,

when a person develops kidney disease, the kidney can't execute their

jobs properly, and can cause drastic problems to the body (Vaidya and

Aeddula, 2022).

If CKD occurs, some serious disorders or conditions can also be

established such as anemia, increased occurrence of infections, fluid

overload, metabolic acidosis, bone disease, and electrolyte imbalances.

The Kidney Disease Improving Global Outcome (KDIGO) classified CKD

into five (5) different stages. These stages are classified based on the

Glomerular Filtration Rate (GFR) which is a test that measures how much

blood passes through the glomeruli and how well it filters properly. The
 patient was diagnosed with Stage 5 which is End-Stage Renal Disease

and is being defined as a GFR of lessthan15mL/min (Hashmi et al., 2023).

End-stage renal disease (ESRD), is the final and permanent stage of

chronic kidney disease in which kidney function ultimately declines to the

point that the kidneys can no longer function independently. Patients with

end-stage kidney disease must receive dialysis or a kidney transplant to

survive (JohnsHopkins,2023).

Based on the patient's medical diagnosis, one of the nursing diagnoses for

his condition is Excess Fluid Volume due to decreased urine output

because, in people with CKD, their kidneys are not removing excess fluids

and electrolytes such as sodium which causes increased retention of

sodium and water in the body. If this complication can't be managed

immediately, it can cause too much excess fluid in the body which causes

swelling or edema in various parts of the body (Fresenius Kidney Care,

n.d).

ii. Etiology

PREDISPOSING FACTORS Present Justification

Gender Men may be at the higher risk of having kidney failure

sooner than women. Due to the variations of hormone
levels where increased testosterone level in men
might result in a decline in renal function decline.
Moreover, men’s kidneys may not be defended by
estrogen since the hormone is higher in women until
menopause (National Kidney Foundation 2021).
-> The patient is a male
Family History Strong family history of CKD puts people at increased
of Kidney risk for developing the disease. Studies in the US
Disease have verified the high frequency of CKD among
relatives of patients with end-stage kidney disease
(ESKD), with 14% of screened relatives having GFR
60 ml/min/1.73m2. First or second-degree relatives of
ESKD patients had a 2 to 3 times higher risk of
developing the condition, as well as a higher
likelihood of being obese and having undiagnosed
hypertension. (National Library of Medicine, 2021)
-> The father of the patient died years ago due to
kidney failure.

Abnormal The kidney can be too small or their parts may be

Kidney made in an unusual way. Sometimes pee flows
Structure backwards making the kidney swollen or damaged.
Cysts (fluid filled sacs) can develop in the kidney and
affect their work.

PRECIPITATING Present Justification

FACTORS

Hypertension Hypertension causes the wall to begin as the artery adds

thickness to resist the strain and that results in a narrow
lumen. Once the lumen reduces oxygen levels, and blood
gets to be delivered, that results in the kidneys ischemic
injury to the glomerulus of the nephron. Immune cells like
foaming macrophages enter the damaged glomerulus and
start releasing growth hormones like transforming growth
component B-1. These expand causes for the mesangial
cells to regress going back to the younger condition of stem
cells known as mesoangioblasts and secrete extracellular
matrix outcomes in glomerulosclerosis, scarring and
hardening. It reduces the nephrons ability to filter blood and
eventually results in chronic renal illness (PMC, 2018).
-> The patient’s blood pressure is 180/100mmHg
Diabetes Mellitus Diabetes mellitus is the leading cause of CKD and ESRD. As
glucose it would create an inflammation in which it would
damage the efferent arteriole and may cause arteriosclerosis
which builds pressure and tends to increase back pressure
and increase GFR. In response, mesangial cells secrete
more and create fibrosis and results in glomerulosclerosis
which decreases GFR. (PMC, 2018)
-> The patient was diagnosed with Diabetes Mellitus 2

Obesity Obesity is one of the most significant yet changeable risk

factors for ESRD in the twenty-first century. Glomerular
hypertrophy and hyperfiltration may hasten kidney injury by
raising glomerular capillary wall tension and lowering
podocyte density. A three- to four-fold increase in the risk of
CKD was associated with obesity (BMI 30 kg/m2) in men and
morbid obesity (BMI 35 kg/m2) in women at any stage in
their lifespan. Through oxidative stress, endothelial
dysfunction, prothrombotic condition, hypervolemia, and
abnormal adipokines, obesity may play a role in the
development of kidney injury. (PMC, 2018)
-> The patient’s BMI is 30.2 kg/m2, considered as Obesity
Class I.

Smoking Smoking can increase the likelihood of CKD through

endothelial dysfunction, glomerulosclerosis, oxidative stress,
prothrombotic shift, and proinflammatory state.
Smoking more than 20 cigarettes a day increased the risk of
developing CKD in a trial with 7476 non-diabetic subjects.
Another study found a 31% rise in blood creatinine >0.3
mg/dl for every additional five cigarettes smoked per day.
(PMC, 2018)
-> The patient is a smoker for 25 years who consumes 10
sticks per day as verbalized by the patient’s wife.
 Alcoholism Alcohol is one of the toxic compounds that the kidneys are
responsible for filtering out of the blood, among other things.
Small amounts of alcohol can be easily filtered and
eliminated, but excessive alcohol harms the kidneys ability
to function, making it impossible for them to effectively
remove alcohol from the blood. While this is typically not a
problem with normal drinking, abusive or excessive drinking
can have a major negative impact on the kidneys ability to
filter out toxins. (National Kidney Foundation, 2017)
-> The patient drinks alcohol for at least 3x a week for 9
years already as verbalized by the patient’s wife.

Frequent use of According to the National Kidney Foundation, as many as 3

medications that percent to 5 percent new cases of CKD each year may be
damage kidney caused by the overuse of these painkillers. Once kidney
disease occurs, contributed use of the problem drug makes
it worse.

iii. Symptomatology
Signs/Symptoms Present Justification

Neurologic

Mental Delirium Chronic kidney disease is commonly

associated with neurologic diseases
influencing both the peripheral and central
nervous systems, resulting in behavioral
abnormalities such as mental and cognitive
dysfunctions (Rencez, et al, 2019).

Confusion Confusion is common occurrences in

dialysis patients as a result of electrolyte
imbalances that can occur after a dialysis
session, a condition known as dialysis
disequilibrium syndrome, or as a result of
medical or surgical complications (Gungor,
et al., 2021)
Incomprehensible & Due to the accumulation of uremic toxins in
Agitated the bloodstream. As kidney function
declines, the kidneys are less effective at
filtering waste products and toxins, leading
to higher levels of these substances in the
body. These elevated toxins levels can
affect the brain and nervous system,
leading to cognitive disturbances.
-> The patient cannot talk well. He did not
even recognize his daughter.

Restlessness Restless is a common form of sleep

disturbance in chronic kidney disease
(CKD) patients. It is linked to iron
deficiency, renal disease anemia, uremic
toxin accumulation, and peripheral
neuropathy (National Foundation 2020).

Integumentary

Uremic Frost It occurs due to the buildup of urea and

other waste products in the bloodstream,
which are normally filtered by healthy
kidneys. As these toxins accumulate to
dangerous levels, they may be excreted
through sweat, leading to the crystallization
of urea on the skin’s surface, manifesting
as a powdery, frost-like substance.
-> Upon inspection, the patient’s entire face
and body is having uremic frost.
Excoriation Patients with chronic kidney disease
(ESRD) experiences excoriation as a
secondary effect of their condition. ESRD
often leads to the accumulation of uremic
toxins in the bloodstream, which can cause
severe itching and pruritus, prompting
patients to scratch their skin excessively.
This repeated scratching can result in
excoriated skin, as the constant friction and
pressure lead to the loss of the skin’s outer
layer.
->As indicated in the physical examination it
reveals that patient has excoriation
Circulatory

Anemia Your kidneys produce an important

hormone called erythropoietin (EPO).
Hormones are chemical messengers that
travel to tissues and organs to help you
stay healthy. EPO instructs your body to
produce red blood cells. When you have
kidney disease, your kidney cannot
produce enough EPO. Low EPO levels can
cause your red blood cell count to drop and
anemia to develop. Anemia is common in
people with kidney disease. Anemia can
develop early in the course of kidney
disease and worsen as the kidneys fail and
can no longer produce EPO (Kidney Org.,
2019)

Hyperkalemia Hyperkalemia can occur if your kidneys are

not working properly. The kidney’s job is to
balance the amount of potassium ingested
with the amount lost in urine. Potassium is
ingested through the foods and liquids we
consume. It is excreted in the urine after
being filtered by the kidneys. The kidneys
can frequently compensate for high
potassium levels in the early stages of
kidney disease. However, as kidney
function deteriorates, they may be unable
to remove sufficient potassium from your
body.
Hypertension When the kidneys experience low blood
flow, they behave as if the cause is
dehydration. As a result, they react by
secreting hormones that stimulate the
body’s retention of sodium and water.
Blood vessels expand and blood pressure
rises.

Tachycardia Patients with advanced kidney disease

frequently experience uremic frost, a striking
skin condition. Due to the early
implementation of renal transplant therapies,
uremic frost is now a common symptom of
advanced chronic kidney disease. Knowing
about this condition can serve as a life-saving
cue to start urgent dialysis.
The patient's cardiac rate is at
111 bpm.

Respiratory

Orthopnea Acute kidney failure can cause fluid to

accumulate in your lungs, causing
shortness of breath or as if you can’t
breathe is a potentially distressing
symptom of chronic kidney disease. Many
factors can contribute to this condition,
including low iron levels, extra fluid in the
lungs, and even anxiety (National Kidney
Foundation, 2022)

Tachypnea Tachypnea is a common and should be

expected in patients with end-stage renal
disease as the body attempts to
compensate for a stressed cardiovascular
system, and
rapid breathing also expels extra carbon
dioxide as a buffer mechanism for the
presence of increased acids (Yang, X.,
2018)
Rales & Crackles Kidney damage is irreversible once it has
occurred. Potential complications can affect
almost any part of your body and include:
fluid retention, which can cause swelling in
your arms and legs, high blood pressure, or
fluid in your lungs (pulmonary edema),
which can be detected by crackles in the
lungs (Sumida, K. et al., 2020)

Urinary (Excretions)

Decreased Urine Output The kidneys, which play a pivotal role in

filtering waste and regulating fluid balance,
become progressively impaired. As kidney
function declines, the ability to produce
urine diminishes, leading to a reduced
output and the accumulation of waste
products and excess fluid in the body.
-> The patient’s urine output decreased:
200 cc in 24 hours.

Renal
Low GFR It exhibits a low glomerular filtration rate
(GFR) because the kidneys have sustained
extensive damage and dysfunction,
resulting in a reduced ability to filter waste
products and excess substances from the
bloodstream. The GFR serves as a critical
marker of kidney function, and a low GFR
is a hallmark of advanced kidney disease,
necessitating the need for renal
replacement therapy such as dialysis or
transplantation to support the patient’s
filtration needs.
-> the patient has a low GFR of 15 ml/min
on September 12, 2021 as revealed in the
doctor's order sheet.
Others:

Bipedal & In bipedal edema the failing kidneys

Periorbital Edema struggle to remove excess salt and fluids
from the body, leading to fluid retention and
edema. Periorbital edema, or swelling
around the eyes, can also occur in ESRD
due to the impaired filtration of waste
products, causing fluid and toxins to
accumulate in the tissues, including those
around the eyes.

-> Upon further assessment, you can see

the presence of bipedal edema Grade 4+
and eyes are swollen and puffy.

Metabolic Acidosis Metabolic acidosis in kidney failure is a

condition where the kidneys are unable to
effectively remove excess acid from the
body, leading to an accumulation of acid in
the bloodstream, which disrupts the body’s
pH balance.
 Ascites As kidney function declines, fluid and waste
products can accumulate, leading to
increased fluid retention, which can
manifest as ascites, the abnormal
accumulation of fluid in the abdominal
activity.
-> Upon inspection ascites were noted and
abdominal girth is 48 inches.

v. Schematic Diagram

V. Narrative:

The journey toward chronic kidney disease (CKD) in this case was shaped
by a multitude of factors, both predisposing and precipitating.

Predisposing factors included the patient’s age and gender, as he was 55-

year-old male, a demographic known to be at an increased risk of chronic

health conditions like CKD (Stevenset al., 2006). The family history of

diabetes and hypertension also played a pivotal role, adding genetic

predisposition to the mix (Levin et al., 2013). Lifestyle factors such, such

as 25-year history of smoking approximately 10 cigarettes per day, further

compounded the risk. Smoking, a well-established risk factor, is

associated with vascular and renal damage, making it a significant

contributor to CKD (Hallan et al., 2011).

With the diagnosis of Type 2 Diabetes Mellitus (DM), the patient’s path

toward CKD became more fraught. Diabetes is a recognized precursor to

kidney complications, particularly when not well-managed (Gross et al.,

2005). Adding to this challenge, the patient increased alcohol consumption

following the DM diagnosis, intensifying the risk. As a consequence, the

progression continued with poorly managed diabetes, resulting in early

signs of kidney dysfunction. These signs included difficulties in breathing

and sleep, which are indicative of renal involvement (Gross et al., 2005).

The culmination of this journey was an emergency department admission

marked by severe clinical manifestations, ultimately confirming the

diagnosis of severe CKD.

The signs and symptoms evident in the clinical presentation of CKD are

instrumental in shaping the patient’s experience. These include the

presence of uremic frost, pale nail beds and palms, bipedal edema

(Grade 4+), and mental delirium and

confusion. Uremic frost, a visible manifestation of severe kidney

dysfunction, is observed on the patient’s face and body. Pale nail beds

and palms are indicative of anemia, a common complication of CKD.

Bipedal edema, particularly at Grade4+, is attributed to the kidney’s

reduced ability to remove excess salt and water, leading to fluid

retention. Mental delirium and confusion can be associated with

advanced CKD.

In End Stage Renal Disease (ESRD), the kidney is no longer able to filter

waste products from the blood and excrete them, as well as retain

necessary amounts of water, proteins, and electrolytes. Multiple organ

functions will be affected and altered, and the system's homeostasis will

be disrupted, leading to a number of system changes, including the ABG

values and other laboratory findings. Additionally, this condition prevents

the hormone erythropoietin from stimulating the red blood cells, which is

why ESRD patients almost always exhibit anemia-related symptoms. The

kidneys' inability to remove extra potassium from the blood when they are

failing causes hyperkalemia, which is harmful even though it helps to

mitigate the effects of sodium. Since the kidney is unable to distinguish

between electrolytes that should be eliminated and those that should be

retained, it also affects the sodium and water balance. This results in an

increase in vascular volume or blood pressure, which may lead to

additional symptoms of having too much pressure or volume, such as

edema and ascites, or it may be a sign that the patient is unaware of his

condition.

Planning kidney replacement therapy and transplant evaluation both

require referral to nephrology. The presence of symptoms, not just the

level of GFR, is taken into consideration when deciding whether to start

kidney replacement therapy. Encephalopathy, pericarditis, and pleuritis

brought on by severe uremia are examples of

urgent indications. Otherwise, patients who exhibit uremic symptoms

(such as nausea, vomiting, poor appetite, a metallic taste in their mouth,

pericardial rub or effusion, asterixis, or altered mental status), electrolyte

abnormalities (such as hyperkalemia or metabolic acidosis), or volume

overload (such as pulmonary or lower extremity edema) that are resistant

to medical treatment should have the option of starting dialysis

considered. Patients should be informed of available treatments and

encouraged to participate in decision-making. Information on the potential

side effects of CKD and the various types of kidney replacement therapy

should be included in early education. The best results can be achieved

with living donor kidney transplants carried out prior to or soon after the

start of dialysis, which is why kidney transplantation is regarded as the

best treatment option for ESRD (Chen et al., 2020). Home hemodialysis,

peritoneal dialysis, in-center hemodialysis, and conservative care without

dialysis are a few examples of alternative treatments for ESRD.

Hemodialysis is a common and effective treatment for individuals with

advanced chronic kidney disease (CKD), particularly when the kidneys

are no longer able to adequately perform their primary function of filtering

waste products and excess fluids from the blood. Hemodialysis is a life-

saving procedure that helps maintain electrolyte balance and remove

toxins from the body.

Interventions aimed at managing CKD encompasses a multifaceted

approach. Continuous vital signs monitoring, including blood pressure,

heart rate, respiratory rate, oxygen saturation, and temperature, forms the

cornerstone of care. Maintaining optimal 43 oxygen through oxygen

therapy and respiratory support is crucial to improving oxygen saturation

levels. Meticulous skin care is essential to address uremic frost, involving

gentle cleansing to remove deposits. Management of fluid balance is

achieved

through meticulous tracking of fluid intake and output. Cardiovascular

issues are managed with medications and interventions to control blood

pressure and heart rate. Ultimately, timely treatment and management

of CKD-related complications contribute to an enhanced quality of life

for the patient, reducing symptoms and discomfort (NurseKey,2020).

PATHOPHYSIOLOGY

DUE TO ETIOLOGICAL FACTORS

DECREASED GFR

HYPERTROPHY OF REMAINING
NEPHRONS

INABILITY TO CONCENTRATE URINE

FURTHER LOSS OF NEPHRON FUNCTION

LOSS OF NON-EXCRETORY AND EXCRETORY

FUNCTION