I.

INTRODUCTION
 Chronic or irreversible, renal failure is a progressive reduction of
functioning renal tissue such that the remaining kidney mass can no
longer maintain the body’s internal environment. CRF can develop
insidiously over many years, or it may result from an episode of a cure
renal failure from which the client has not recovered. The incidence of
CRF varies widely by state and country. In the United States, the
incidence is 268 new cases per million populations.
Chronic renal failure affects many body systems. It can also lead to
many complications. This is the goal of health care providers, to prevent
any occurrence of complications. One of the complications of CRF is
hyperparathyroidism; this is due to the compensatory mechanism of the
parathyroid hormone once it detects any alteration in the calcium level of
the body.
It is important for clinicians to recognize the problem of
hyperparathyroidism early in the course of chronic kidney disease so that
growth of the parathyroid glands can be prevented or halted, and
excessive secretion of hyperthyroidism can be controlled to help minimize
the adverse consequences on bone and mineral metabolism, which may
lead to bone pain and bone fractures, decreased growth in children,
muscle weakness, and elevations in the calcium phosphorus product,
which contributes to calcification of the heart valves and blood vessels
and contributes to the high cardiovascular mortality in patients with
advanced kidney disease.

II. OBJECTIVES
General objectives:

This case study is designed for the student nurse to become practiced,
knowledgeable and mannered in delivering holistic care for patients diagnosed
with Chronic Renal Failure.

Specific Objectives:

Skills
• To demonstrate the vision/mission of the school which is service oriented,
research motivated, technology enable and Vincentian inspired.
• Imply appropriate medical nursing management for Chronic Renal
Failure.
 Knowledge
• Discuss the anatomy and physiology of the Renal system.

• Define and familiarize Chronic Renal Failure.

• Learn about major etiologic causes of Chronic Renal Failure.

• Identify clinical manifestations and risk factors of Chronic Renal Failure.

• Be familiar with the pathophysiology of Chronic Renal Failure.

• Be acquainted with the different drugs, its actions, and perform obligatory
nursing responses for each.
• Plan for a suitable nursing care

Attitude
• Establish a nurse-patient interaction through exchanging of thoughts and
information
• Institute bond between the student nurse and the patient.
III. ANATOMY AND PHYSIOLOGY:

The Urinary System

The major functions of the urinary systems are performed by the kidneys
and the kidneys plays the following essentials roles in controlling the composition
and volume of body fluids:

1. Excretion. The kidneys are the major excretory organs of the body. They remove
waste products, many of which are toxic, from the blood. Most waste products
are metabolic by- products of cells and substances absorbed from the intestine.
The skin, liver, lungs, and intestines eliminate some of these waste products, but
they cannot compensate if the kidneys fail to function.
2. Blood volume control. The kidneys play an essential role in controlling blood
volume by regulating the volume of water removed from the blood to produce
urine.
3. Ion concentration regulation. The kidneys help regulate the concentration of
the major ions in the body fluids.
4. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in the
blood and the respiratory system also play important roles in the regulation of pH
5. Red blood cell concentration. The kidneys participate in the regulation of red
blood cell production and therefore, in controlling the concentration of red blood
cells in the blood.
6. Vitamin D synthesis. The kidneys. Along with the skin and the liver, participate
in the synthesis of vitamin D.
Kidneys
The kidneys balance the urinary excretion of substances against the

accumulation within the body through ingestion or production. Consequently, they

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

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

regulation, erythropoietin production, insulin degradation, prostaglandin synthesis,

calcium and phosphorus regulation and Vitamin D metabolism.

The kidneys are located retroperitoneally, in the posterior aspect of the

abdomen. On either side of the ventral column. They lie between the 12 th thoracic
and third lumbar vertebrae. The left kidney is usually positioned slightly higher than
the right. Adult kidneys are average approximately 11 cm in length, 5 to 7.5 cm in
width, and 2.5 cm in thickness. The kidney has a characteristic curved shape, with a
convex distal edge and a concave medial boundary.

Ureters, Urinary Bladder and Urethra

The ureters are small tubes that carry urine from the renal pelvis of the kidney
to the posterior inferior portion of the urinary bladder. The urinary bladder is a hollow
muscular container that lies in the pelvic cavity just posterior to the pubic symphysis.
It functions to store urine, and its size depends on the quantity of urine present. The
urinary bladder can hold from a few milliliters to a maximum of about 1000 mL of
urine. When the urinary bladder reaches a volume of a few hundred mL, a reflex is
activated, which causes the smooth muscle of the urinary bladder to contract and
most of the urine flows out of the urinary bladder through urethra. The urethra is a
tube that exits the urinary bladder inferiorly and anteriorly. The triangle-shaped
portion of the urinary bladder located between the opening of the ureters and the
opening of the urethra is called trigone. The urethra carries urine from the urinary
bladder to the outside of the body.

Renal Blood flow and Glomerular Filtration

The kidney receive 20% to 25% of the cardiac output under resting
conditions, averaging more than 1 L of arterial blood per minute. The renal arteries
branch from the abdominal aorta at the level of he second lumbar vertebra, enter the
kidney, and progressively branch into lobar arteries. Blood flows from the interlobular
arteries through the afferent arteriole, the glomerular capillaries, the efferent arteriole
and the peritubular capillaries. Some of the peritubular capillaries carry a small
amount of blood to the renal medulla in the vasa recta before entering the venous
drainage. The blood leaves the kidney in venous system closely corresponding to the
arterial system: interlobular veins, arcuate veins, interlobar veins, and the renal vein.
The renal circulation then empties into the inferior vena cava.
IV. VITAL INFORMATION:

Name: RD
Age: 63 y.o
Sex: Female
Address: Tapulang, Maayon Capiz
Religion: Roman Catholic
Occupation: Housewife-unemployed
Date and time admitted: August 26, 2009; 3:30 pm
Ward: Female Medical Ward
Chief Complaints: Difficulty of breathing
Impression/ Admitting Diagnosis: Chronic Renal Failure secondary to
Hypertensive Nephrosclerosis.
Final Diagnosis: Chronic Renal Failure secondary to Hypertensive
Nephrosclerosis
Attending Physician: Dr. R. Blancaver

V. CLINICAL ASSESMENT

A. Nursing History:
Mrs. RD, has been complaining for body malaise and light headedness at
home. Then 2 weeks prior to admission, she had a sudden onset of difficulty
of breathing. Her family was so alarmed that they immediately consult for
medical help and was admitted to Saint Anthony College Hospital, though the
patient was even refusing to seek medical assistants since she is scared to
be hospitalized.

B. Past Health Problems/Status:

Mrs. RD was a healthy person before her admission.
Whenever she feels something’s not good about her health, she just ignores
it, and prefers to take a rest than taking therapy. Her delivery for all 6 children
was at home with a midwife’s help. Her family has a history of hypertension,
and she happened to have one. She had her maintenance drug which she is
not continually responding to. But on March 2009, she was convince to have
a medical check-up in the city, and was later found out that she has Renal
Failure. It is the first time that Mrs. RD, was admitted to a hospital.
 C. Family History of Illness

FAMILY GENOGRAM

RD SP
– HTN, Stroke - Old age

RD RD-
- Accident RD-73 RD-70 68,HTN,
CRF

Legends:

- Diseased

- Produced offsprings

- Male - Female - Pt
VI. BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND
Mr. RD is a 63-year-old female, married living at Tapulang, Maayon
Capiz. She was born on October 10, 1945 in Maayon. She is married for 39
years now and has six children. She was not able to finish her studies since
their family was not financially capable to send them to school. She is a
dedicated Roman Catholic, who attends regular Sunday Mass, and prays
novena and Rosary. Her favorite foods to eat are cooked vegetables and dried
fishes. She usually stays at home and takes good care of her family instead
being out and claims that she easily gets tired.

VII. CLINICAL INSPECTION

A. Vital Signs
Admitting V/S: V/S taken during care:

BP= 100/70 mmHg BP= 140/100 mmHg

CR=40 bpm CR=57 bpm

RR=25 bpm RR=24 bpm

T= 36OC PR=60 bpm

T=37.2OC

B. Anthropometric Measurements:
Height= 58 inches
Weight= 42 kilos
BMI= 19.309

C. Physical Assessment

I. General Appearance
Mrs. RD appears to be uncomfortable and weak. She is very
conscious and coherent and even answers to questions attentively. She
lies on the bed uncomfortably. She is not well groomed, has messy hair
but has clean clothes.

II. Skin, Hair and Nails

Skin- pallor, brown in complexion, with good skin turgor.
Hair- short, thin and coarse.
Nail- long-uncut, dirty nails; pallor nailbed, with weak
capillary refill (approximately within 3 seconds).

III. Head and Face

 Head-no mass palpated. Skull is normocephalic.
Face- both cheeks are swelling.

IV. Eyes, Ears, Nose, Mouth and Throat

Eyes-White sclera, pale conjunctiva, no discharges noted,
pupils are equally round and reactive to light and
accommodation
Ears- symmetrical, no discharges noted; acuity poor to
whispered voice.
Nose-nasal mucosa pink, no sinus tenderness; without flaring of
nostrils
Mouth- with dry and pale lips

V. Neck and Upper Extremities

Neck- no mass palpated, without lesions, no enlargement of
lymph nodes and pain.
Hands- has numerous bruises on both hands, mostly on
forearms.

VI. Chest, Breast and Axilla

Chest- is flat and symmetrical.
Breast- no mass or lump palpated.
Axilla-is clean and but with few hair.

VII. Respiratory System

Thorax is symmetric. Lungs are resonant. Breath sound vesicular.
No crackles, no wheezes, no rales heard.

VIII. Cardiovascular System

Heart is bradycardia. No murmurs or any abnormal sound heard.

IX. Gastrointestinal System

Abdomen is soft, flat, tender.

X. Musculoskeletal System
Poor range of motion in some joints. No evidences of swelling or
deformity.

D. General Appraisal

I. Speech
 Speaks clear and coherent.

II. Language
Uses Hiligaynon as language.

III. Hearing
Has poor hearing sense.

IV. Mental Status

Mentally healthy, very conscious and responds
appropriately when asks.

V. Emotional Status
Emotionally weak. Shows signs of anxiety and fear at
certain times.

VIII. LABORATORY AND DIAGNOSTIC DATA

A. Hematology

August 26, 2009

NORMAL
TEST RESULT SIGNIFICANCE
VALUES

WBC 7.4 109/L 4.5-11.0 Normal

Results is below
RBC Male: 4.6- the normal level,
6.2 thus indicating
RBC 1.63 1012/L
RBC Female: renal malfunction
4.2-5.4 and thereby
causing anemia
Results is below
Hgb Male:
the normal level,
135-180 thus indicating
Hemoglobin 46 g/L
renal malfunction
Hgb Female: and thereby
120-160 causing anemia

Hematocrit 0.14 vol Hct Male: Result is below

the normal range
0.40-0.54 thus, showing
anemia and renal
 Hct Female:
disease
0.37-0.47

Neutrophils 73.0 % 50-70 High

Eosinophils 1.0 % 0-3 Normal

Basophils 0.0 % 0-1 Normal

Lymphocytes 25.0 % 25-30 Normal

Monocytes 0.0 % 0-8 Normal

Platelets 156 109/L 150-130 Normal

B. Urinalysis

August 26, 2009

TEST RESULT NORMAL SIGNIFICANCE

VALUE
Physical Exam:
Color Pale straw
Transparency Slightly Hazy
Macroscopic
Exam:
pH: 5.0 4.5-8 Normal
1.015 1.005-1.035 Normal
Specific Gravity:
Positive (+)
Protein: negative (-)
Glucose:
Microscopic Laboratory results
Exam: revealed that there is
presence of albumin;
Amorphous U/P occasional this indicates that
RBC: 1-3 /hpf 0-2
the glomerular
0-5
WBC: 15 % cannot filter large
Epithelial cells: Few molecules such as
Occasional that of albumin. It
Bacteria
also revealed that
there is bacterial
infection as
evidenced by
presence of bacteria,
pus cells and red
cells in the urine
C. ABG Analysis

August 26, 2009

TEST RESULT NORMAL SIGNIFICANCE

VALUE
pH 7.180 7.35-7.45
pCO2 20.3 35-45 mmHg
pO2 141.5 80-100 mmHg Low pH value
and low pCO2 but
HCO3 7.3 22-26 mmol/L high value of pO2
TCO2 17.7 and low value of
HCO3 indicates
ABE -20.1 METABOLIC
SBE -19.6 ACIDOSIS.
SBC 10.5
O2 Sat 98.6 % 97-100 % Normal

D. Cross Matching Result Slip

August 27, 2009

Blood Type “O” Rh (+)

Serial no. # 006459, # 006461, # 016093
Cross Matching COMPATIBLE
Note 450 cc, WB; secured at PNC
Blood Type “O” Rh (+)
Serial no. # 006460
Cross Matching COMPATIBLE
Note 450 cc, WB; secured at PNC
IX. PATHOPHYSIOLOGY
XI. NURSING MANAGEMENT

CONCEPT MAP
XII. DISCHARGE PLANNING

On the night of August 27, 2009, Mrs. RD suffered from a sudden and
severe seizure. Patient was restless. Due to complications that occurred from her
disease…Mrs. RD passed away. Thus, the usual and accepted discharge plan
format is inapplicable.
Nonetheless, proper post-mortem care was done by Nurses on duty.
Spiritual aides were given. She received holy communion and was anointed.
Family was also instructed to give due Necrological service.
XII. BIBLIOGRAPHY

Websites:

♂www.scribd.com
♂www.wikipedia.org
♂www.nursingcrib.com
Books:
♀Karch, Amy M. Lippincott’s Nursing Drug Guide, 2009
♀Braunwald, Eugene et al. Harrison’s Principle of Internal
Medicine. 15th Ed. 2001
♀Doenges, et al. Nurse’s Pocket Guide. 10 ed.
th

♀Ackley, Betty J et al. Nursing Diagnosis Handbook. 7 ed.2006

th

♀Muscari, Mary E. Lippincott’s Pediatric Nursing. 4 ed. 2005

th

♀Huether, Sue E, et al. Understanding Pathophysiology. 2 nd

Ed.2009
♀Larsen,Hal. Diagnostic Test Made Incredibly Easy.2006
♀MIMS 109 ed. 2006
th