Capitol University

Corrales, ext./ Osmeña sts. Cagayan de Oro city

A CASE STUDY
On
CHRONIC KIDNEY DISEASE SECONDARY TO
DIABETIC NEPHROPATHY; ANEMIA

MR. RYAN MANUEL V. NASOL, RN

Clinical Instructor

August 14, 2010

I. Introduction
Diabetes mellitus is a condition in
which the pancreas no longer produces
enough insulin or cells stop responding to
the insulin that is produced, so that
glucose in the blood cannot be absorbed
into the cells of the body. Symptoms
include frequent urination, lethargy,
excessive thirst, and hunger. The
treatment includes changes in diet, oral
medications, and in some cases, daily
injections of insulin.
The most common form of diabetes is
Type II, It is sometimes called age-onset or
adult-onset diabetes, and this form of
diabetes occurs most often in people who
are overweight and who do not exercise.
I. Introduction

Anemia is a condition that occurs

when the number of red blood cells
(RBCs) and/or the amount of hemoglobin
found in the red blood cells drops below
normal. Red blood cells and the
hemoglobin contained within them are
necessary for the transport and delivery of
oxygen from the lungs to the rest of the
body. Without a sufficient supply of
oxygen, manytissues and organs
throughout the body can be adversely
affected. Anemia can be mild, moderate or
severe depending on the extent to which
the RBC count and/or hemoglobin levels
 are decreased.
I. Introduction

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 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
complications, such as cardiovascular
disease, anemia or pericarditis.
II. CLIENT’S PROFILE

1.Health Perception and Health

Management Pattern
Chief complaint:
• Patient was admitted due to shortness of
breath and edema formation. Last
admission was June this year also due to
shortness of breath, at Zamboanga del
Sur
History of present illness;
• The patient was diagnosed with Diabetes
Mellitus 16 years ago
II. CLIENT’S PROFILE

Last October 2009, the patient manifested signs

and symptoms of glaucoma. While he was at
home, he got so angry which elevated his blood
pressure. He then manifested signs like redness
around his right eye. He also reported blurring
and pain in his right eye. They went to see a
doctor and were referred to a specialist of
ophthalmology at Cebu City. After the
consultation, he agreed with the advice of
undergoing laser treatment to treat his
glaucoma. After six sessions, they went home to
Aurora. After going home, he was still
complaining about blurredness of vision in his
right eye. Few weeks later, the other eye
became affected and he reported blurredness in
both eyes.
II. CLIENT’S PROFILE

When they went back to the specialist they

were advised to undergo a surgery which costs a
huge amount of money. When they asked for any
assurance for the blurredness to be relieved after
undergoing the surgery, they were given the
assurance which made them decide not to take the
risk. Few weeks later the right eye became totally
blind and the left eye had an angular blurredness.
When they went back to the specialist for the third
time, it was found out that the left eye had a blood
clot covering the pupil.
Patient was diagnosed with CKD last
December 2009.
2weeks prior to admission, there was onset of
shortness of breath, with dizziness and edema.
By the physicians order, the patient started
taking Sodium Bicarbonate and Calcium
Carbonate, but did not comply with the other drug
which is Ketosteril.
II. CLIENT’S PROFILE

• General Appearance:
• Patient appears weak, and bloated.

• Social History:
• Before diagnosed, patient is a chain
smoker, smokes almost three packs of
cigarette a day and a heavy drinker. He
socializes with his friends and goes home
late and very drunk at least twice a week.

• History of allergies:
• Patient doesn’t have any known allergies
II. CLIENT’S PROFILE

2. Nutrition and Metabolic Pattern

Eating pattern:
• The patient has fair-good appetite for eating.
There are times that he could consume a
whole share of his diet but there are also
times in which he doesn’t have any appetite
at all which sometimes coincide with his
tantrums. No known eating discomforts.
Special diet:
• Patient was ordered low salt, low fat ,
diabetic diet. No intravenous fluid was used
II. CLIENT’S PROFILE

Physical examination of the mouth:

• MOUTH: Lips are pale, and dry so as his mucosa.
His tongue is midline and dental caries noted, with
missing teeth, and pale gums.
• PHARYNX: Uvula is midline and tonsils not
inflamed
• NECK: Trachea is midline and thyroids are not
palpable and normal.
• SKIN: General color is pale with rough texture,
poor turgor and warm temperature. Ecchymosis
was noted on both arms
Other pertinent data:
• Presence of wound dressing on right neck due to
Intra-jugular catheter insertion for his dialysis.
II. CLIENT’S PROFILE
3. Elimination Pattern
Bowel Pattern:
• Patient normally defecates once/ twice in a day
with a semi-formed, yellowish stool. No
discomforts on bowel elimination. No problems
with hemorrhoids and incontinence. With
normoactive bowel sounds.
Urination pattern:
• Patient urinates almost 4-6 times a day, with
yellow or amber colored and scanty urine.
Physical assessment:
• The patient had normoactive bowel sounds and
tympanic when auscultated. His abdomen is
globular and symmetrical.
II. CLIENT’S PROFILE

4. Activity – Exercise Pattern

• Before hospitalization, patient’s type of exercise is
only walking around home premise almost
everyday. The patient likes to talk and have night-
outs with friends as leisure.
Cardiovascular status:
• Orthopnea reported, with capillary refill of 3
seconds. Palpitations are reported upon exertion.
Precordial area is flat. The point of maximal
impulse is at the apical area and the Apical rate
reaches up to 89 and arrhythmia is noted. Heart
sounds are faint and irregular. The peripheral
pulses are asymmetrical and faint.
II. CLIENT’S PROFILE
Respiratory status
• Breathing pattern is irregular. Wheezes
heard at left lung, ronchi and crackles at
the right.
• The Anteroposterior Lateral ratio is 1:2 and
the lung expansion is symmetrical. Tactile
fremitus is also symmetrical. The lungs are
resonant when the back is percussed. The
patient has a productive cough with white
sputum.
• Patient has Oxygen inhalation via nasal
cannula, regulated at 4 LPM.
• Activities of daily Living
• Range of motion symmetrical, with
staggering gait.
II. CLIENT’S PROFILE
5. Cognitive – Perceptual Pattern
Level of consciousness:
• Patient is conscious and oriented to
time, place, and person.
• Patient’s emotional state is anxious.
Head: Head is normocephalic, with
symmetrical facial movements. Hair is fine,
and scalp is clean.
Eyes: Eyelids are symmetrical. Periorbital
region is on edema, while conjunctiva is
pale. Sclera is icteric. Pupils have sluggish
reaction to light, having a size of 4mm on
the right eye and 3mm on the left.
Peripheral vision is decreased/limited.
II. CLIENT’S PROFILE
• Ears: External Pinnae is normoset. No ear
discharges, tympanic membrane intact. Gross
hearing is intact
• Nose: Nasal septum is midline, mucosa is
pale, both nasal openings are patent, with no
discharges and non tender sinuses
• Cognition: Primary language is vernacular.
Patient is a college graduate. No speech deficit
reported, but has some memory changes due to
aging process.
• Pain: There is intermittent pain in lower
extremities but disappears later on even with
nonpharmacologic treatment is used
II. CLIENT’S PROFILE
6. Sleep – Rest Pattern

Usual sleep/rest pattern:

• Patient usually sleeps less than 8hours
during night time, but takes time to sleep
during daytime. Sleeping pattern is
usually disturbed due to his irritability, and
coughing, and environmental factors.
• Patient has no known history on sleep
disturbances.
II. CLIENT’S PROFILE
7. Self-perception and Self-concept Pattern
• The patient is anxious about his condition, and
oftentimes verbalizes that he doesn’t understand
his feeling.
8. Role – Relationship Pattern
Marital status: Patient is married, with one child.
• Age and health of significant other: Spouse is 50
years old and in good condition.
• Patient’s family has a history of diabetes on the
maternal side.
• Living together with family, but does not have any
occupation. Patient’s family is worried for patient’s
condition, and is worried regarding financial
support.
• Financial support system would be the wife’s
income.
II. CLIENT’S PROFILE
9. Sexuality – Reproductive Pattern
• Patient’s sexual relation has been greatly
affected by his condition
• Patient has no known prostate problems
at present. Does not exercise monthly
testicular examination.
• Penis: No discharges noted, and no
lesions
• Scrotum: patient manifested hydrocele
in the scrotum
II. CLIENT’S PROFILE
10. Coping – Stress Tolerance Pattern
• One of the recent stressful situations that
complicates his feelings is financial crisis of the
family. His wife took her advance pay from work to
support hospitalization, and some relatives
donated some of their money for financial help
• Patient usually manages stress by talking to
friends, also for relaxation
11. Value – Belief Pattern
• Religion: Patient X is a Roman Catholic. His
family continues to pray and ask for guidance from
God to help them pass through this difficult time
that they are having. They used to go to church
every Sunday, but was not able to comply with it
since patient’s hospitalization.
III. ANATOMY and PHYSIOLOGY
III. ANATOMY and PHYSIOLOGY
III. ANATOMY and PHYSIOLOGY
III. ANATOMY and PHYSIOLOGY
III. ANATOMY and PHYSIOLOGY
III. ANATOMY and PHYSIOLOGY
III. ANATOMY and PHYSIOLOGY
III. ANATOMY and PHYSIOLOGY
IV. PATHOPHYSIOLOGY
 Type II Diabetes Mellitus

LEGEND:
Chronic elevations of glucose in the blood. -Diagnosis

Increased pressure and solutes (glucose) - Implications

in the circulatory system.

Increased pressure and solutes in the

vessels of the kidneys.

CHRONIC KIDNEY DISEASE

Decreased production of erythropoietin

by the kidneys

Thickening of the glomerulus and impairment of

the selective permeability of the kidneys
Allowing the larger molecule to pass.
Decreased stimulation of the Bone Marrow
to produce Red Blood Cells

Red Blood Cells and Albumin are not filtered and

thus are included in the urine formation Decrease levels of Red Blood Cells
3.11 (normal= 4.2-5.4)
Decreased Hemoglobin Level
10.7 (normal= 12.0-16.0)
Decreased Hematocrit level
34.8 (normal= 37.0 – 47.0)
Decreased Serum Albumin
-2.89mg% (normal value= 3.8-5.1)
Anemia
 V. LABORATORY RESULTS
COMPLETE BLOOD COUNT
JULY 24, 2010

TEST RESULT UNIT NORMAL VALUES INTERPRETATIONS

WBC 11.5 10ˆ3/uL 5.0-10 HIGH

RBC 3.2 10ˆ6/uL 4.2-5.4 LOW

HGB 9.1 g/dl 12.0-16 LOW

HCT 28.2 % 37-47 LOW

DIFF. COUNT        

LYMPHOCYTE 6.6 % 17.4-48.2 LOW

NEUTROPHIL 82.4 % 43.4-76.2 HIGH

MONOCYTE 9 % 1.0-3.0 HIGH

EUSINOPHIL 1.9 % 0.0-2.0 HIGH

BASOPHIL 0.1 % 1.0-2.0 NORMAL

PLATELET 200 10ˆ3/uL 150-450 NORMAL

 V. LABORATORY RESULTS
JULY 26, 2010

TEST RESULT UNIT NORMAL VALUES INTERPRETATIONS

WBC 11.9 10ˆ3/uL 5.0-10 HIGH

RBC 3.11 10ˆ6/uL 4.2-5.4 LOW

HGB 8.7 g/dl 12.0-16 LOW
HCT 27.6 % 37-47 LOW

DIFF. COUNT        

LYMPHOCYTE 2.9 % 17.4-48.2 LOW

NEUTROPHIL 90.6 % 43.4-76.2 HIGH

MONOCYTE 6.2 % 1.0-3.0 HIGH

EUSINOPHIL 0.3 % 0.0-2.0 HIGH

BASOPHIL 0 % 1.0-2.0 LOW

PLATELET 200 10ˆ3/uL 150-450 NORMAL

 V. LABORATORY RESULTS

JULY 29, 2010

TEST RESULT UNIT NORMAL VALUES

WBC 9.6 10ˆ3/uL 5.0-10

RBC 3.91 10ˆ6/uL 4.2-5.4

HGB 10.7 g/dl 12.0-16
HCT 34.8 % 37-47

DIFF. COUNT
LYMPHOCYTE 6.2 % 17.4-48.2
NEUTROPHIL 84.1 % 43.4-76.2
MONOCYTE 0.8 % 1.0-3.0
EUSINOPHIL 0 % 0.0-2.0
BASOPHIL 0 % 1.0-2.0

PLATELET 200 10ˆ3/uL 150-450