IDENTIFICATION DATA

Client’s name : Mr. Suresh ku. panda

Age : 58years
Sex : Male
IP. No. : 190228072
DOA in dialysis : 25.02.2019 @8.00am
Ward :dialysis
Bed no. : 16
Education : Intermediate
Occupation : Business
Marital status : Married
Religion : Hindu
Address : Berhampur , Ganjam
Provisional diagnosis : CKD (IV) with hypertensive nephropathy
Final diagnosis : CKD (IV)

I. Presenting Chief Complaints:

Leg swelling,high amount of saliva,presence of htn,dryness of skin
K/C/O HTN with CKD-IV reported in low GC state.
II. History of Present Illness
A 58 year old businessman was a K/C/O HTN with CKD-IV reported in the state of
secretion of saliva and swelling in extremity for which he got admitted to dialysis unit of
sum hospital on 25.02.2019@ 8.00 am.Patient undergone last dialysis on 23.02.2019.
III. Past Medical History:
K/C/O-HTN for 20 days and CKD-IV on dialysis and anti hypertensive drugs. Last dialysis was
done on 23.02.2019 in SUM and IMS,BBSR.
III. Past surgical History
AV shunt was there on left hand
IV. Family History:
Nothing suggestive
V.Family Characteristics :Nuclear family
VI -Socio economic history : He is a Businessman .Electricity and water facilities are available in
house. Drainage facility is proper.
 Income per month: The monthly income is approx. 50,000/-.
 Expenditure : approx.: 20,000 /- rupees
 Recreational facilities : Present
 Medical facilities : Available
 V. Personal History:-
 Habits & hobbies: He smokes cigarette since many years and drinking alcohol also
 Elimination pattern:
 Bladder elimination:-he passed stool 2 times/dayi,no cnstipation
 Bowel elimination: - he voids 6-8 times a day
 Sleeping pattern: normal sleeping pattern 6-7 hrs/day
 Nutritional history :
Vegetarian / non-vegetarian: Non-vegetarian
Likes / dislikes: He likes all kinds of vegetables & fish.
ix. PHYSICAL EXAMINATION:

General Appearance: - conscious

Emotional state: - Anxious

Body built: - normal

Level of consciousness: - Conscious

POSTURE: Normal,not presence of lordosis or scoliosis

Height: - 162cm

Weight: - 69 kg

BMI: - 26.291Kg/M2

SKIN CONDITION:-

Colour: - Black

Texture: - Dry and itchy skin

Temperature: - Warm

Lesions: - No lesions found

HEAD AND FACE:-

Scalp: - not presence of dandruff and lice

Hair: smooth hair

Face: - anxiety

EYE:-

Eye brow: Eye brows are symmetrical and equal hair distribution.

Eye lashes: symmetric and equal hair distribution.

Eye lids: - normal and no swelling are found.

Pupil: right eye: - Reactive (constrict) to light

Left eye: - Reactive (constrict) to light

Conjunctiva: - light pink

Vision: - Normal

EAR:-

External ear: - no discharge

Tympanic membrane: -no perforation

Hearing: - normal

NOSE:-

External nose: - no discharge

Nasal septum: - normally straight

Nasal deviation: - no deviation

Nostrils: - pink in color

MOUTH AND PHARYNX:-

Lips: - dry

Odors of mouth: - Absent

Teeth: - No caries

Tongue: - Moist ,no inflammation

Uvula & tonsils: - Normal

Throat: - Normal

NECK:-

Lymph nodes: - Not enlarged

Ranges of motion: - Flexion, extension and rotation present

Thyroid gland: - Not enlarged

CHEST:-

Inspection: - Symmetrical expansion and relaxation of chest wall , no use of intercostals spaces

Auscultation: Crepts in both sides of lungs left side more than that of right

Palpitation: No enlargement present

Percussion: - no accumulation of fluid in both side of pleural space.

ABDOMEN:-

Observation: - Umbilicus vertical and central, No engorge veins and visible pulsation

Auscultation: - The bowel sound 6 per minutes

Palpation: - Abdomen tenderness present ,No palpable lump/mass, presence of hepatomegaly

Percussion: - not presence of any fluid

EXTREMITIES:-
Nails: Normal

Joints: not presence of contractures

Peripheral pulse: - Present

 Right radial pulse:- 100 b/m left radial pulse:- 100b/m

 Right popliteal pulse:- 102 b/m left popliteal pulse:- 100 b/m
 Rt. Posterior tibial pulse:- 100 b/m lt. posterior tibial pulse:- 100b/m
 Rt. Dorsal pedis pulse:- 98 b/m lt. dosalis pedis pulse:- 100b/m

Heart sound: - S1& S2 sounds heard. No murmur sound heard.

Capillary refill: - Present, within 1 sec.

NEUROLOGICAL TEST:-

Mental status-conscious
GCS-E4V5M4
Reflexes-Biceps, triceps and achilis reflexes are present
Planter test-Negative
Vital Signs: (on Day of history collection.i.e. 26.03.2019)
S. No. Vital Sign Normal Value Patient’s Value
1. Temperature 98.6 99°F

Pulse 60 – 80 Beats/M. 100 Beats/M.( left

radial pulse)
2.
96 Beats/ min( right
radial pulse)
3. Respiration 14-20 Breath/M. 26 Breath/M.
Blood Pressure 120/80mmHg 200/120mmHg( right
arm)
4.
194/120 mmhg ( left
arm)
SPO2 95%-100% 76 % with air and 96%
5.
with ventilator support
 CASE STUDY
CHRONIC KIDNEY DISEASE(CKD)

DEFINITION: This disease is a progressive, irreversible deterioration in renal function in which

the body is unable to maintain metabolic, fluid and electrolyte balance .It occurs with a
gradual decrease in the function of the kidneys over time. The result is accumulation of
nitrogenous waste products in the blood and uremia.CKD affects every body system.
ETIOLOGY
ACCORDING TO BOOK ACCORDING TO PATIENT
 Diabetes mellitus
 Chronic high blood pressure  High Blood pressure
causing nephrosclerosis
 Glomerulonephritis
 Autoimmune diseases
 Hypertension and Diabetes
accounts for close to 70% of all
CKD

PATHOPHYSIOLOGY:-

When a large proportion of the body’s nephrones are damaged CKD occurs.

As the nephrones die off the undamaged ones increase their work capacity and for this
reason even though up to 50% of nephrons are lost the patient is usually without symptoms
and this stage is called silent stage.

The renal insufficiency stage occurs when the patient has lost 75% of nephron functions and
some signs of mild kidney disease are present.

End stage renal disease occurs when 90% of the nephrons are lost. Patients experience
chronic and persistent abnormal kidney function

Uremia develops and patients develop problems in all body systems . If left untreated the
patient with uremia dies often within weeks
CLINICAL MANIFESTATION :

ACCORDING TO BOOK ACCORDING TO PATIENT

Disturbance in water balance:
 Edema of the lower extremities
and abdomen,
 shortness of breath
 crackles and wheezes may be
present
 Pedal edema
 History of present illness shows that he
had SOB and after admission he was on
ventillatory support for two day
 Pleural effusion present on right lung
more than that of left.so pleural tap was
done on 03.03.2019

 neck vein distension

 polyuria, oliguria and anuria
Disturbance in electrolyte balance:
 Hypernatremia/hyponatremia
 Hyperkalemia  He was admitted in a state of
 Hypocalcemia unconsciousness,Breathlessness,irritability
 Hyperphosphatemia ,low spo2,tachypnea
Disturbance of removal of waste
products:  Pale skin was there
 Weakness and fatigue, confusion,
seizure, twitching movements of  On day of admission respiration was fast
extremities, nausea, vomiting and and deep.Metabolic acidosis was there.
lack of appetite and a metallic or  Anemia present i.e Hb% count is 7.5g/dl
bad taste in the mouth. on admission.
 Yellowish pale skin  High urea and creatinine i.e84mg/dl and
Disturbance in maintaining Acid-Base 5.45mg/dl on admission
balance:  Low GCS was there after admission
 Metabolic acidosis–lethergy,
stupor and coma. Kussmaul’s
respiration

Disturbance in Hematilogic Function:

 Anemia

 Impaired WBC and immune

functions
 Impaired platelate function
creates a risk for bleeding

DIAGNOSTIC EVALUATION OF ACUTE PANCREATITIS

According to Book

 Urine analysis
 Elevated BUN,creatinine levels
  Urine sodium levels less than 10mEq/L
 Acidosis
 Anemia
 Electrolyte
abnormalities(Hyper/Hyponatremia,hperkalamia,hypermagnesemia.hyperphostemia
and hypocalcemia)
 Hypertension
 Pericarditis
 Platelet dysfunction
 Dialysis

ACCORDING TO PATIENT:

 Blood investigations shows that patient had low Hemoglobin, RBC ,PCV and low MCHC level.
 High levels of Serum Urea and Creatinine, Magnesium and mild high level of Chloride.
 Metabolic acidosis was present during admission
 USG abdomen and pelvis shows that he had ,B/L grade IV chronic renal disease
 CT Thorax report shows that he has B/L minimal pleural effusion (R>L), few fibrotic areas in
bilateral upper lobes

1. Blood investigation:
Date 02.03.2019 03.03.2019 04.03.2019 05.03.2019 06.03.2019 07.03.2019
Hb% 7.5 6.4 5.9
PCV 29.4 20.2
TLC 9.22 6.47
RBC 3.97
MCHC 29.3

Platelets 273 124

PT/INR 10.3/0.99
APTT 33.1
Chloride 108 103 100 101 102 102
Na+ 140 137 133 134 134 133

K+ 4.5 5 4.3 4.9 4.3 5.0

Ca++ 9.33 8.6
Mg++/Phosphate 2.68/4.45 2.1/5.21
Urea 65 72 51 105 78 115
Creatinine 7.17 8.6 5.5 8.5 6.1 8.2
Bilirubin(T) 0.04
Bilirubin(UC) 0.22
SGOT/SGPT 25.6/21.0
Albumin/Globulin 3.76/2.29
Protein 6.05
HHH -VE

Date ABG Value

02.03.2019 PH-6.47
PCO2-21.5 mmhg
PO2-166 mmhg
K+-4 .7mmol/l
Na+-146 mmol/l
HCO3-22.9 mmol/l
Glu-179
Lact-6.83
Hb-10.2g/dl

03.03.2019 PH-7.395
PCO2-37.5 mmhg
PO2-76.5 mmhg
K+-4 .9mmol/l
Na+-138 mmol/l
Cl-107mmol/l
HCO3-23.1 mmol/l
Glu-88mg/dl
Lact-0.9mmol/l

Hb-10.2g/dl

04.03.2019 PH-7.547
PCO2-26.8 mmhg
PO2-69.6 mmhg
K+-4 .5mmol/l
Na+-132 mmol/l
Cl-101mmol/l
HCO3-23.1 mmol/l
 Glu-84mg/dl
Lact-1.2mmol/l
Hb-6.3g/dl
05.03.2019 PH-7.427
PCO2-34.2 mmhg
PO2-120 mmhg
K+-4 .5mmol/l
Na+-131 mmol/l
Cl-101mmol/l
HCO3-23.1 mmol/l
Glu-94mg/dl
Lact-1.1mmol/l
Hb-7.3g/dl

06.03.2019 PH-7.397
PCO2-38.5 mmhg
PO2-66.3 mmhg
K+-4 .5mmol/l
Na+-138 mmol/l
Cl-105mmol/l
HCO3-23.6 mmol/l
Glu-94mg/dl
Lact-0.5mmol/l
Hb-6g/dl
07.03.2019  PH-7.417
 PCO2-36.3 mmhg
 PO2-57.9 mmhg
 K+-4 .9mmol/l
 Na+-133 mmol/l
 Cl-98mmol/l
 HCO3-23.6 mmol/l
 Glu-94mg/dl
 Lact-0.6mmol/l
 Hb-5.7g/dl
MANAGEMENT

According to Book According To Patient

Diet: Diet:
 Calorie are high to maintain weight
and energy needs
 Protein is usually restricted but is  High protein renal diet(patient is on
increased for a patient on dialysis hemodilysis)

 Sodium restricted diet  No sodium

 Potassium is restricted

 Calcium may be increased  Tab Sandoz 500mg p/o twice a day

 Phosphorus is restricted
 Saturated fat and cholesterol are
 Tab Rosufit Cv 10 p/o once daily
restricted
 Iron,folic acid ,vitamins and minerals  Tab Zeroz-o 40mg p/o twice a day
to suppliments
Medications:
 Diuretics  Inj Lasix 20mg IV twice a day

 ACE inhibitors, angiotensin receptor  Tab Minipress XL 5mg p/o twice a

blockers, calcium channel blockers or
day,Tab Nicardia R 20mg p/o thrice a
beta blockers for hypertension
day,Tab Carvidon MR 3.5 mg p/o
twice a day,Tab Embeta XR 50mg p/o
once a day
 Phosphate binders
 Tab Zeroz-o 1 tab twice a day
 Calcium and vitamin D suppliments
 Agents to lower potassium
Dialysis:
 Total 4 hemodilysis was done (before
 Hemodialysis and peritoneal dialysis
admission he had 13 no of
hemodilysis).During hemodilysis inj
25% dextrose-100ml an one PRBC
was given and without
heparine.Contineous vitals was
checked including HGT.Dialysis was
 for a duration of 3-4 hour.

NUTRITIONAL PLAN:
 High protein renal diet
 For 1st two days ryles tube feeding with protein and albumin powder 4 tsf each was
given 4 hourly.
 On 3rd day of admission orally high protein renal diet was given
PROGRESS NOTE

SL. DATE NURSE’S NOTES

NO.
1. 02.03.2019 1st day of admission. He was admitted to medicine ward for getting
treatment then he shifted to micu bcoz he was unconscious with high BP,low
HR,and also low SPO2.Abnormal ABG i.e.metabolic acidosis, GCS-E2V2M2
for which he was intubated and foley catheter along with ryles tube was
inserted. After admission in MICU he was connected with mechanical
ventilator with AC/PC mode . Vitals was BP-190/120mmhg,HR-96/min,SPO2-
96% and RR-26/min. All the advised drugs were given along with advised
blood investigations were done. Dialisys was done as he had high serum urea
and creatinine with high RR. Bed side USG whole abdomen and pelvis done
along with chest X-Ray.@ 11.30 am he was assessed GCS-E3V3M6.Ryles tube
feeding was started. Central line was inserted @ 10am with all aseptic
measures. I/O-1200/940ml.Fluid restriction was there i.e.1200ml/24hours.
Mouth care was done every four hourly as he was intubated. Tracheal
suctioning was done with all aseptic measures. Skin care was given by
sponging and applying moisturizer to kept the skin intact.
2. 03.03.2019 On 2nd day of admission he was conscious and oriented i.e.GCS-
E4V5M6,Vitals were BP-170/100mmgh,HR-89/min,SPO2-96% with ventilator
support.@ 8.30am the intensivist planned for T-Piece try and extubation. He
put in T-Piece @10am but didn’t maintained SPO2 and also high RR. Again he
was on ventilator support with CPAP mode.ABG done every 4 hourly. Blood
investigations reports were collected. It showed the abnormality that he had
low Hb%,PCV,RBC,MCHC and high level of serum urea and creatinine. Slightly
incresase level of serum phosphate and magnesium. USG abdomen and
pelvis showed that he had IV stage of renal disease and cholilithiasis.X-Rays
chest shows that he had mild pleural effusion .Dialysis was done for 2 hours.
One PRBC was given.Cardiology consultaion was done.I/O-1000/1030ml.
.
3. 12.12.2018 3rd day of admission.He was extubated on previous night. He is on NIV .He
had high temperature. Inj paracetamol 1gm IV was given.Other vitals were
stable.Maintain SPO2 @4lit/min of O2.ABG done.He removed ryles tube by
self and orally started high protein renal diet.I/O-1260/90ml. He didn’t
passed stool fpr two days and Syp Duphalac 30ml was advised to be given
@bedtime. All advised drugs were given along with inj dobutamin
infusion.Total intake 750ml/24hours was advised.Orally soft renal diet was
given.Small and frequent feeding was given.Blood investigations was done
and report collected. Sr.Urea-51 and creatinine-5.5.
4 05.03.2019 4th day of admission.Cardiology consultaion revealed that he had DCMP(EF-
40%).Dialysis (19th)was done for 4 hours. One PRBC was given. Vitals
stable.He had hemoptysis.CT Thorax done. Blood investigations done . Cr-
8.5,Urea-105,Na-133,K-4.9.abg done.Tracheal secretions send lab for culture
test along with sputum for AFB.
5 06.03.2019 5th day of admission.CT thorax report showed that consolidation in right
upper lobe and bilateral lower lobes.bilateral mild to moderate pleural
effusion.No growth in tracheal secretion. Sputum showed no growth of
AFB.Other blood investigations were done like Hb%-5.9,Ur-78,Cr-6.1. One
PRBC was given.

APPLICATION OF VIRGINIA HENDERSON’S NEED THEORY IN NURSING CARE:-Virginia

Henderson was born on 30th November, 1897, in Kansas City, Missouri and dies on17th
march 1996.
֍ She called as “the Nightingale of modern nursing”, “Modern- day mother of
nursing”, “The 20th century Florence Nightingale” & “Little Miss3*5”.
֍ She earned her Diploma in nsg. From the Army school of nursing in 1921, B.Sc. in
1932, M.A. in 1934.
֍ She worked as a teaching nursing in 1923, member of faculty & research
associate.
֍ She was honored at the Annual meeting of the nursing and allied health section
os the medical library association.
֍ She created a basic nursing curriculum for nursing in 1937.
֍ She revised Harmer’s classic textbook of nursing and wrote 5th edition in 1939.
֍ She was founding member of ICIRN (Interagency council on information
resources for nursing).
֍ She developed the theory in 1950-1970.
֍ She proposed 14 components of basic nursing care:-
 Breathe normally
 Eat &drink adequately
 Eliminate body waste
 Move and maintain desirable posture
 Sleep and rest
 Select suitable clothes- dress and undress
 Maintain body temperature within normal range
 Keep body clean and well groomed and protect from injury
 Avoid dangers in the environment and avoid injuring others.
 Communicating with others in expressing feelings.
 Worship according to one’s faith.
 Work in such a way that there is a sense of accomplishment.
 Play and participate in various forms of recreation. Learn, discover, or
satisfy the curiosity that leads to normal development
 CASE PRESENTATION on
ckd

SUBMITTED TO: SUBMITTED BY:

Prof. SASMITA DASH ITISHREE PRADHAN

HOD,MEDICAL SURGICAL MSC NURSING 1ST YEAR

NURSING