210489573 62553270-case-study-on-chronic-kidney-disease

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OBECTIVES OF CASE STUDY
GENERAL OBJECTIVES:-
The general objective of the case study is to gain the comprehensive knowledge about the disease to
gain the practical exercise about the Adult Health Problem and also to gain Practical experience working
with a patient having chronic kidney disease and to give holistic patient care according to their need.
SPECIFIC OBJECTIVES:-
The specific objectives of the case study are given below:-
 To assess the patient and find out need of patient according to nursing process.
 establish a nurse-client relationship to the client, as well as to the family by rendering a
therapeutic nurse-patient relationship;
 gather adequate information to be used in the development of the study
 present the clients personal data;
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 illustrate the patient’s family tree and trace significant diseases which may be of relevance to the
study
 trace the health history of the client and the family by collecting information both of the past and
present illnesses;
 To provide holistic nursing care to the client to all ages using nursing process.
 To manage promptly as necessary to built up comfort.
 To provide psychological support to the patient
 To apply knowledge from the science, nursing theory and other related courses to plan and
implement nursing care.
 To provide continuous care till discharge and follow-up care.
 Counsel and make aware the patient party about importance of continuity of medicine and
psychological support to prevent from worsens.
 To provide the discharge teaching to the patient and family member.
BIOGRAPHIC DATA
1) HEALTH HISTORY
A) DEMOGRAPHIC DATA
 NAME: laxman kumar pandit
 AGE: 68yrs
 SEX: male
 ADDRESS: Permanent: nayapati -6, jorpati
 RELIGION: Hindu
 EDUCATION iliterate
 DATE OF ADMISSION: 068/4/6
 DATE OF DISCHARGE: 068/4/17
 IP NO. : 200821/410159
 OCCUPATION: farmer
 MARITAL STATUS: married
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 ATTENDING DOCTOR: Dr. P.K.C
 INFORMATION SOURCE: patient and his son
 DIAGNOSIS: CKD 5
 BLOOD GROUP: A +ve
 BED NO: 205
• WARD: nephrology
B) CHIEF COMPLAINTS: Swelling of legs, face for 2 days
C) HISTORY OF PRESENT ILLNESS: According to the patient’s, he come for haemodialysis, due
to increased shortness of breath during dialysis he was admitted in the nephrology ward. His general
condition is ill looking and oriented with time place and person.
D) HISTORY OF PAST ILLNESS:
• According to the patient’s party, he is undergoing regular dialysis and is under
antihypertensive medicine.
• ALLERGIES
According to the patient, he doesn’t have any allergic reaction to any factors.
.
PREVIOUS HOSPITALIZATION: Nepal medical college teaching hospital for the diagnosis of
CKD
• OPERATIONS OR SPECIAL TREATMENT: no any
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E) FAMILY HISTORY:
 Type of family: joint
 No. of Family Members: 8
Fig.1 Family Tree
Table 1 Family Medical history
DISEASE FATHER’S RELATION MOTHER’S RELATION
Tuberculosis Absent Absent
Cancer Absent Absent
Heart disease Absent Absent
Jaundice Absent Absent
Epilepsy Absent Absent
Psychological Absent Absent
Hypertension Present Present
HEALTH SEEKING PRACTICE: He belongs to literate family, According to laxman kumar pandit,
they were not dependent in superstitious beliefs. If someone becomes ill in their family they take
homemade medicine then some times go to hospital.
• PERSONAL HISTORY:
• Health Habits:
Smoker but has left 1-2 months ago, Non alcoholic,
Non vegetarian.
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No food allergy.
Maintain personal hygiene
Religion belief and worship kuldeuta.
• Dietry history:
Non vegetarian.
Foods like egg-curry, rice, daal etc.
• SOCIO-ECONOMIC STATUS:
He belongs to middleclass family. The major source of income is
farming and business. They are the permanent residence of jorpati.
They are well satisfied with their economic status. They have very
good inter relationship in the community.
• ENVIRONMENTAL FACTOR:
 Housing Pattern: Well facilitated
 Waste disposal: They are practicing collective approach to manage the waste
product. Such as temporary container, burning and making compost manure. The
people from nagarpalika also come to take waste from there home.
 Pollution and noise: his house is near the road , so he is very much affected by the
noise of the vehicle and the air pollution caused by the vehicle.
F) DEVELOPMENTAL NEED AND TASK COMPARING WITH NORMAL ADULT CLIENTS
Robert Havighurst’s Developmental Tasks
Developmental
Tasks
Description Passed or
Failed
1. Adjusting to
decreasing physical
strength and health
Older adults also have
to adjust to decreasing
physical strength and
health. The prevalence
of chronic and acute
diseases increase in
old age. Thus, older
adults may be
confronted with life
situations that are
characterized by not
being in perfect
health,serious illness
and dependency on
people.
Passed
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2. Adjusting to
retirement and
reduced income
A central
developmental task
that characterized the
transition into old age
is adjustment to
retirement. The period
after retirement has to
be filled with new
projects, but is
characterized by few
valid cultural
guidelines. The
achievement of this
task may be
obstructed by the
management of
another task, living in
a reduced income after
retirement.
Passed
3. Adjusting to death
of a spouse
Older adults may
become caregivers to
their spouses. Some
older adults have to
adjust to the death of
their spouses. After
they have lived with a
spouse for many
decades, widowhood
may force older
people to adjust to
loneliness, moving to
a smaller place,and
learning about
business matters.
Failed
4. Establishing an
explicit affiliation
with one's aged group
The development of a
large part of the
population into old
age is historically
recent phenomenon to
modern cities. Thus,
advancements
understanding of the
aging process may
lead to identifying
further developmental
Passed
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tasks associated with
gains and purposeful
lives for adults.
5. Meeting social and
civil obligations
Older people might
accumulate
knowledge about life,
and thus may
contribute to the
development of
younger people and
the society.
Passed
6. Establishing
satisfactory physical
living arrangements
Oder adults are
generally challenged
to create positive
sense of their lives as
a whole. The feeling
that life has order and
meaning results in
happiness.
Passed
Eric Erikson’s Developmental Task
Integrity vs. Despair
Erikson felt that much of life is preparing for the middle adulthood stage and the last stage
recovering from it. Perhaps that is because as older adults we can often look back on our lives with
happiness and are contented, feeling fulfilled with a deep sense that life has meaning and we've made
contribution to life, a feeling Erikson called integrity. On the other hand, some adults may reach this
stage and despair at their experiences and perceived failure.
My patient achieved happiness and contentment in his life based on his actions and speeches.
He is faithful and devoted to his religion. He is ready to accept death completely and he has shared his
experiences to his beloved grandchildren. Even though he accepted death fully but his faith and love for
his worshipped God never changed.
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Physical Assessment
Name: Mr.laxman kumar pandit Ward: nephrology Ward
Bed: 205 Age: 68 yrs Sex: male Civil
Status: Married
Vital Signs
Axillary T=97 degree F, PR= 90/ min, RR= 22/ min, BP= 150/80 mmHg.
General survey
Height= 5 ft and 8 inches, weight= 56 kilos,. No signs of distress noted upon assessment, able to
smile, cooperate well, responsive to questions, conscious and alert, conversant. Well oriented. Show
calmness during the examination. He has no IVF infused, and was asleep at initial assessment.
Skin
Skin is brown in color, rough, dry and warm. He has good skin turgor. Brownish discolorations
that resemble wrinkles are observed on face.
Head
Skull is round in shape, symmetrical. No masses noted. Facial movement is symmetrical,
alopecia. Scalp is clear from dandruff and lice. No scars and wounds noted.
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Eyes
Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows have same color
with hair. Eyelashes are evenly distributed and curled outward. Eyelids have no discharges and
bilaterally blink. Upper lid covers the small portion of the iris and cornea. Lacrimal duct openings
(puncta) are evident at nasal ends of upper and lower lid with no tenderness noted. Palpebral conjunctiva
are pinkish in color while the pupils constricted to light, round in shape. He is able to rotate eyes and has
coordinated eye movements.
Ears
Auricle has same color with the skin, has symmetrical shape and located a little bit higher than
the eye. Pinnas are symmetrical with no lesions noted. He has wet cerumen noted on both ears when
pulled down and back for better visualization. he is able to hear on both ears.
Nose
Nose has uniform color and symmetrical in shape. Nasal hairs are very evident when light is
flashed through the nasal passageways; its color is black. No nasal flaring observed upon respiration.
Both nares are patent, air moves freely as client breathes through the nares. Nasal septum is straight and
in midline. Nasal mucosa is pinkish in color, has no discharges and no lesions. No tenderness of sinuses
noted.
Mouth
Lips are a little brownish in color, dry and has cracks. Tongue is in midline, pinkish in color with
thin whitish coating on top. Able to move tongue freely (up & down, side to side). Soft palate is light
pink in color while hard palate is lighter in color. Gums are pinkish in color. Plagues are present on his
teeth
Pharynx
Uvula is found well placed in midline of soft palate. Mucosa is pinkish in color. Tonsils are not
inflamed.
Neck
Trachea is in midline. No tenderness of thyroid noted. No enlargement of the neck noted. he is
able to flex and extend neck and move it laterally (L and R).
Chest and Lungs
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Breathing pattern is regular. Anteroposterior diameter to transverse diameter is in 1:2. Respiratory
excursion is symmetrical (thumb separates to 2-3cm). No tenderness, lump, Presence of breath sound in
all area of lungs
Heart and Central Vessels
Heart sounds are regular. Pulsation of heart is heard in 4 anatomical areas but more audible in
apical area upon auscultation.
Back and Extremities
Peripheral pulses are symmetrical and regular. Nails are long and untrimmed, pinkish in color, and have
a capillary refill time of 2 sec. after blanching; and no clubbing of fingernails were noted.. His hands are
a little rough. Muscle strength is equal on both sides of the upper and lower extremities. He is able to
stand and walk on both feet independently, and his movements are well coordinated. Toes point straight
ahead. And he is able to sit up straight.
Abdomen
His abdomen’s color is same with the rest of the part of the body. His umbilicus is coated with
blackish dirt.
Neurologic Assessment
Cranial Nerves: able to identify aromas by smelling with eyes closed; able to see objects; pupil
constricted to light sensation; able to move eyeball downward and laterally; able to blink eyes; able to
smile, raise eyebrows, puff cheeks and close eyes; able to respond to questions being heard;) has rough
and vibrating sound; able to shrug shoulders, elevate and flex arms and legs against resistance; able to
protrude tongue and move it side to side.
FINDINGS:
 Skin is dry and rough
 Alopecia of hair
 wet cerumen noted on both ears
 plaques are present
 Nails are long and untrimmed
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3) DEFINATION, CAUSE AND PATHOPHYSIOLOGY OF CLIENTS DISEASES.
Definition:
Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal
function over a period of months or years in which the body’s ability to maintain metabolic and fluid
and electrolyte balance fails, resulting in uremia or azotemia. In this condition, the GFR falls below 10%
of the normal rate.
Causes:
 Heredity
 Glomerular dysfunction
 Diabetic nephropathy
 Hypertension
 Glomerulonephritis
 Polycystic kidney disease
 Urinary tract obstruction
 Bladder tumour
 Urethral obstruction
 Hypertensive nephrosclerosis (hardening of the kidney)
Other causes:
 Hiv infection
 Kidney stones
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 Chronic kidney infections and certain cancers
 Regular use of anti – inflammatory drugs
 Vesicoureteral reflux ( a urinary tract problem in which urine travels the wrong way back
towards kidney)
Stages of chronic kidney disease
STAGE DESCRIPTION GFR ML/MIN
1. Slight kidney damage with
normal or increased
filtration
More than 90
2. Mild decrease in kidney
function
60-89
3. Moderate decrease in
kidney function
30-59
4. Severe decrease in kidney
disease
15-29
5. Kidney failure Less than 15 or dialysis
Pathophysiology:
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Numbness and
paresthesia
Decrease insulin
production/sensitivity
Predisposing Factors
Genetics
Age >40
Precipitating
Environment(intrapartal)
Toxin/Virus
Obesity
Decrease Serum Potasium
Elevated Serum
GlucoseIncreased Osmolarity
due to Glucose
Polydipsia Polyuria Polyphagia
Weight loss
Chronic elevation of
Serum Glucose
Impaired immune
function
Infection
Delayed wound
healing
Accelerated
atherosclerosis
Increase
LDL levels
Hypertension
Coronary artery
disease
Diabetic
neuropathy
Small vessel
disease
Diabetic
retinopathy
Diabetic
nephropathy
Loss of vision
End-stage
renal failure
Symmetrical loss
of sensation
Autonomic
neuropathy
Wasting of
intrinsic muscles
Diabetic foot
ulceration
Charcot changes in joints
Neurogenic
bladder
Dry, cracked
skin
Impotence
Gastroparesis

4) COMPARISON OF:
A) SIGNS AND SYMPTOMS
 Neurologic
ACCORDING TO BOOK ACCORDING TO PATIENT
 Weakness and fatigue  present
 Confusion  present
 Inability to concentrate  absent
 seizures  absent
 Restlessness of legs  present
 Burning to soles of feet  present
 Behavior changes  present
 integumetry
 Dry, flaky skin  present
 Thin, brittle nails  present
 Thinning hair  absent
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 cardiovascular
 ACCORDING TO BOOK ACCORDING TO PATIENT
 Hypertension  present
 Pitting edema  present
 Periorbital edema  present
 pulmonary
 Shortness of breath  present
 tachypnea  present
 Kussmaul- type respiration  present
 G.I
 Metallic taste  Absent
 Anorexia, nausea  Absent
 Vomiting, constipation/ diarrhea  present
 Hematologic
 Anemia  present
 Reproductive
 amenorrhea  Absent
 infertility  Absent
 Testicular atrophy  absent
 Musculoskeletal
 Muscle cramps  Present
 Loss of muscle strength  Present
 Bone pain  Present
 Bone fracture  absent
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B) INVESTIGATION
Laboratory test: Blood urea: 119.0 mg/dl
Creatinine:9.1
Na+:139.o
K+:5.2 meq/r
Serum albumin:2.8gm/dl
Hb:9.6gm%
Glucose f:120 mg/dl
Glucose pp : 141mg/dl
USG Done but report was not available
biopsy Done but report was not available
KUB film
It is an ultrasound-based diagnostic medical
imaging technique used to visualize muscles,
tendons, and many internal organs, to capture
their size, structure and any
pathological lesions
with real time tomographic images.
Normal Size in cm:
Left Kidney Right Kidney
Not done
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10.8 +-
0.8
Length 9.7 +-
0.7
4.2 +
-0.5
Width 4.3 +-
0.5
4.8 +-
0.5
Thick 3.9 +-
0.5
1.5 C. Thick 1.5
C) COMPARISON OF MEDICAL MANAGEMENT
The goal of management is to maintain kidney function and homeostasis for as long as possible.
Because of the great deterioration of renal function, the duration of management may vary from months
to years. Nothing can be done to prevent or delay the fatal outcome.
 Control of urinary volume: fluids
are forced since kidney has lessened
ability to concentrate solids. more
fluids about 2litres is needed to
excrete waste. Sometimes
frusemide may be required to
increase urine production.
 My patient was prescribed to drink
lee than 500 ml water in a day.Tab
lasix 40 mg, po, od, is given to my
patient.
 Control of nausea and vomiting:
anorexia, nausea and vomiting tend
to develop when the cretinine
clearance falls below 5ml/min. so
reduction in protein is required to
improve nausea. Blood: 0.8-1.4
mg/dL is the normal. Due to
impaired kidney function,
 Creatinine clearance rate was 10.g
mg/dl on 4/2, 8.5 mg/dl on 068/4/6,
9.7mg/dl on 068/4/9.
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creatinine in the blood elevates.
 Antiseizure agents  Since my patient didn’t develop any
kind of seizure. So antiseizure
agents were not used.
 Antihypertensive agents:
hypertension is managed by
intravascular volume control and a
variety of antihypertensive agents.
 Tab nifedipine 10 mg,tds was given
to my patient to control
hypertension.
 Control of hyperkalaemia will be
treated with I/V glucose and insulin
in a ratio of 3 gm Glucose to 1 unit
soluble insulin.

 Control of anemia: blood
transfusion are frequently required.
 Since my patient didn’t develop
anemia so bllod transfusion was not
done.
 Accurate record of input and output
chart should be maintained
 Input and output chart was
maintained.
 4/6 : 200ml total input and 200ml
was total output
 4/7: 350ml was total input and 250
mi was total output
 4/8: 500ml total input and 350ml
total output
 4/9: 530ml was total intake and 150
ml was total output
 4/10: 450ml total input and 300ml
total output
 4/11: 400 ml total input and 300 ml
total output
 Other therapy: dialysis
It is usually initiated when
the patient cannot maintain
a reasonable lifestyle with
conservative treatment.
 My patient is undergoing regular
dialysis, 2-3 times in a week
COMPARISON OF SURGICAL MANAGEMENT
 Kidney transplantation: it involves
transplanting a kidney from a living donor
to a recipient who has ESRD. The success
rate increases if kidney transplantation
 Kidney transplantation cannot be
performed in my patient because of
hypertension and slow wound healing due
to diabetes mellitus.
17

from a living donor is performed before
dialysis is initiated.
D) COMPARISON OF NURSING MANAGE MENT
The patient with chronic renal failure requires astute nursing care to avoid the complications of reduced
renal failure and the stresses and anxieties of dealing with a life threatening illness.
 Nursing care is directed toward assessing
fluid status and identifying potential source
of imbalance
As a nurse I assessed the fluid status of my patient
by monitoring input and output record closely.
 Implement a dietary program to ensure
proper nutritional intake within the limits
of the treatment regimen.
My patient was prescribed to have fluid less than
500ml/day and was on renal diet. As a nurse I
closely observe the dietary pattern of my patient
 Promote positive feelings by encouraging
increased self care
I encouraged my patient to perform his activity of
daily living by himself and promoted the positive
feelings.
 Provide explanations and information to
the patient and family concerning ESRD,
treatment options and potential
complications
As a nurse I provided explanation to the patient
and his family members about his treatment
options and potential complications.
 Nurse must be familiar with various drugs As a nurse I provided information to my patient
18

and their side effects regarding various drugs used in it.
 Provide emotional support to the patient
and his family because of the numerous
changes experienced.
I provided my patient and his family emotional
support so that anxiety and tension is relieved to
some extent.
5) DRUGS CARD OF MEDICINES
My patient has used the following drug:-
 Tab nifedipine 10mg, tds
 Tab lasix 40mg, od
 Tab pantop 40 mg
 Diclofenac gel
 Tab domel 1 tab
 Tab haloperidol
1. Tab nifedipine
Therapeutic class: antianginal, antihypertensive, calcium channel blocker
Action :antihypertensive agent that inhibits calcium ion movement across cell membranes, depressing
contraction of cardiac and vascular smooth muscles
Therapeutic effect: decreases blood pressure
Indication: chronic stable angina, hypertension
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Contra- indication: severe hypotension
Side effects: peripheral edema, headache, dizziness, (occasional): nausea, muscle cramps and pain,
dyspnea, cough (rare): hypotension, rash, constipation, sexual difficulties
Nursing management: administer on an empty stomach
Do not crush or chew sustained release dosage forms
2. Furosemide
Novosimide; PMS-Furosimide
Classification: Loop diuretics
Indications: Edema d/t heart failure, hepatic impairment
or renal disease. Hypertension.
Action: Inhibits the reabsorption of sodium and chloride from
the loop of Henle and distal renal tubule. Increases renal
excretion of water, sodium, chloride, magnesium, potassium, and calcium. Effectiveness persists in
impaired renal function. Decreased blood pressure.
Dosage: 1 tablet, 200 mg
Contraindication: Hypersensitivity; Cross-sensitivity with thiazides and sulfonamides may occur;
Hepatic coma or anuria; Some liquid products may contain alcohol, avoid in patients with alcohol
intolerance.
Precautions: Severe liver disease; electrolyte depression
Side effects: CNS – blurred vision, dizziness, head ache, vertigo
EENT – hearing loss, tinnitus
CV – hypotension
GI – anorexia, constipation, diarrhea, dry mouth, nausea, vomiting
GU – excessive urination
Derm – photosensitivity, rash
F and E – dehydration
Nursing Responsibilities:
1. Assess fluid status. Notify physician or other health care professional if thirst, dry mouth,
hypotension, or oliguria occurs.
20

2. Monitor blood pressure and pulse before and during administration.
3. Monitor blood glucose closely; may cause increased blood glucose level.
4. Caution patient to change positions slowly to minimize orthostatic hypotension.
5. Advise patient to contact health care professional immediately if muscle weakness, cramps,
nausea, dizziness and numbness occurs.
6. Caution older patients or their caregivers about increased risk for falls.
3. tab pantop
Generic name: pantoprazole
Functional class: proton pump inhibitor
Action: it inhibits the secretion of hcl in the stomach by specific action on the proton pumps of the
patietal cells.
Dose and routes:
Adult: 40 mg/day (PO)
In pathological hypersecretory conditions: adult I/V 80 mg over 12 hours
Indication:
Peptic ulcer,zollinger ellison syndrome, NSAIDS associated peptic ulcer
Contraindication: lactation, hypersensitivity to drug
Side effects:
CNS: headache, insomnia, mental depression, confusion
GI system: diarrhea, abdominal pain, constipation
INTEG: rash, peripheral edema
Muscular system: myalgia( pain in the muscles)
4. diclofenac gel
therapeutic class: NSAID, antipyretic, non narcotic analgesic
action: NSAID that inhibits prostaglandin synthesis reducing the intensity of pain
therapeutic effect: produces analgesic and anti-inflammatory effects
indication: osteoarthritis, rheumatoid arthritis, pain, primary dysmennorrhea
contra indication: hypersensitivity to aspirin, diclofenac
side effects: headache, abdominal cramps, constipation, diarrhea, nausea
21

5. Domperidone
Motilium (1 tab, 100 mg)
Classification: Anti-emetic and anti-vertigo
Mode of Action: Domperidone is a dopamine-receptor blocking agent. Its action on the dopamine-
receptors in the chemo-emetic trigger zone produces an anti-emetic effect.
Interactions:
• Concomitant administration of anti-cholinergic drugs may inhibit the anti-dyspeptic effects of
MOTILIUM.
• Anti-muscarinic agents and opioid analgesics may antagonize the effect of MOTILIUM
• MOTILIUM suppresses the peripheral effects (digestive disorders, nausea and vomiting) of
dopaminergic agonists.
• Since MOTILIUM has gastro-kinetic effects, it could influence the absorption of concomitant
orally administered medicines, particularly those with sustained release or enteric coated
formulations.
• As MOTILIUM interferes with serum prolactin levels, it may interfere with other
hypoprolactinaemic agents and with some diagnostic tests.
• Antacids and anti-secretory agents lower the oral bioavailability of domperidone. They should be
taken after meals and not before meals, i.e. they should not be taken simultaneously with
MOTILIUM.
• Reduced gastric acidity impairs the absorption of domperidone.
Oral bioavailability is decreased by prior administration of cimetidine or sodium bicarbonate
Side Effects:
• Allergic reactions, such as rash or urticaria, have been reported.
• Abdominal cramps have been reported.
• Reversible raised serum prolactin levels have been observed which may lead to gynaecomastia.
• Where the blood brain barrier is not fully developed (mainly in young babies) or is impaired, the
possible occurrence of neurological side-effects cannot be totally excluded
Nursing Responsibilities:
22

1. Assess for extra-pyramidal effects such as jerking and tongue protrusion.
2. Check for hypotension.
6. Haloperidol
Therapeutic class: antipsychotic
Action: an antipsychotics agent that competitively block postsynaptic dopamine receptors
Therapeutic effect: produces tranquilizing effect
Indication: treatment of psychotic disorders
Contra indication: CNS depression, hepatic disease
Side effects: blured vision, constipation, dry mouth, peripheral edema, difficulty urinating,
decreased thirst, dizziness, drowsiness
Nursing consideration:
• take with food or milk
• donot mix liquid formulation with coffee or tea
• use a sunscreen during sun exposure to prevent burns
7. inj. Novapid 4 units
Func class: antidiabetic
Chem.. class: exogenous unmodified insulin
Action: decreases blood glucose, by transport of glucose into cells and the conversion of glucose to
glycogen, indirectly increases blood pyruvate and lactate, decreases phosphate and potassium
Uses: DM type 1 and 2
Doses and routes:
Adult: subcut dosage individualized, give within 15 min before or 20 min after starting a meal
Side effects:
EENT: blurred vision, dry mouth
INTEG: flushing, swelling, redness
META: hypoglycemia
SYST: anaphylaxis
Contraindication: hypersensitivity to protamine
Precaution: pregnancy
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Nursing Interventions:
1. Assess for symptoms of hypoglycemia such as: anxiety, restlessness, tingling in hands, feet,
lips or tongue, chills, cold sweat, confusion, pale skin, difficulty in concentration,
drowsiness, excessive hunger, head ache, irritability, nightmares or trouble sleeping, nausea,.
2. Assess for symptoms of hyperglycemia: confusion, drowsiness, flushed and dry skin, rapid
deep breathing, polyuria, loss of appetite, nausea & vomiting, unusual thirst.
3. Monitor body weight periodically. Changes in weight may necessitate changes in insulin
dose.
4. Monitor blood glucose every 6 hours during therapy.
6. Store insulin in refrigerator. Do not use if cloudy, discolored or unusually viscous.
7. Rotate site of infection.
8. Instruct patient on proper techniques for administration.
9. Explain to the patient that this medication controls hyperglycemia but does not cure
diabetes.
6) SUMMARY OF CLIENT DAILY PROGRESS REPORT IN HOSPITAL
DATE TIME TEMPERATU
RE
PULSE RESPIR
ATION
BP SUMMARY
04/O8/068 2am
6pm
98 degree F
97.6 degree F
80/m
88/m
20/m
28/m
200/80mm
of hg
210/80
mm of hg
Pt’s g/c is seems
satisfactory, vital signs
monitored with rise in
blood pressure.
Prescribed medicine
carried out. Input and
output chart maintained.
Paln for haemodialysis
tomorrow. No any
complain from the
patient side.
04/09/068 12:30p
m
98 degree F 82/m 24/m 210/100
mm of hg
1:20p
m
98 degree F 90/m 20/m 210/100
mm of hg
pt’s g/c seems
satisfactory. Vital signs
24

are taken and recorded
with rise in blood
pressure. haemodialysis
done. Patient in normal
diet. Prescribed
medication carried out.
No any specific
complain from patient
side.
04/10/068 2pm 98 degree F 100/m 22/m 200/90
mm of hg
6pm 101.6 degree F 110/m 24/m 210/80
mm of hg
Pt’s g/c is satisfactory.
Vital signs are taken and
recorded with rise in
blood pressure and
temperature. Tab
paracetamol and cold
compresses given to the
patient.All prescribed
medication was carried
out. Patient is on normal
diet.
04/11/068 10am 97 degree f 90/m 20/m 210/90
mm of hg
2pm 97 degree f 88/m 20/m 210/90
mm of hg
Pt’s general condition is
satisfactory. Vital signs
are taken with rise in
blood pressure. prescribed
medicine carried out.
Normal bowel and
bladder habit. Patient
complain is dry and
itching over skin of
hands and legs. So he is
in dermatology
consultation.
Dermatology department
prescribed him coconut
oilto apply in itching and
dry areas three times a
day.
04/12/068 10 am 97 degree f 92/ min 20/min 180/80
mm of hg
pt’s g/c seems satisfactory.
recorded with rise in blood
pressure. haemodialysis done
25

through left femoral vein. Put
the sand bag pressure at the
femoral site for 2 hours. Patient
in normal diet. Prescribed
medication carried out. No any
specific complain from patient
side.
2pm 98 degree f 88/min 20/min 180/70
mm of hg
04/13/068 10am 98 degree f 80/min 22/min 150/90
mm of hg
Patient general condition
seems satisfactory. Vital
signs taken with rise in
blood pressure. Prescribed
medicine carried out.
Normal bladder habit but
bowel habit is disturbed.no
any such complain from
patient side
mm of hg
Patient general condition seems
satisfactory. Patient general
condition seems satisfactory.
Vital signs taken with rise in
blood pressure. Prescribed
medicine carried out. Normal
bowel and bladder habit. No
any itching on the patient’s skin
mm of hg
mm of hg
pt’s g/c seems satisfactory.
recorded with rise in blood
pressure. haemodialysis
done through left femoral
vein.dialysis three times a
week that is on
Sunday,Wednesday and
Friday. Patient in normal
diet. Prescribed medication
carried out. No any specific
complain from patient side.
mm of hg
mm of hg
Pt’s g/c is improved. Vital
signs taken with rise in
blood pressure. All
prescribed medication was
26

carried out. . Discharge on
o4/17/068.
mm of hg
Patient general condition
seems fair. Vital signs are
taken and recorded with
rise in blood
pressure.prescribed
medicine carried
out,normal bowel and
bladder habit.dialysis three
times a week. That is on
Sunday, Wednesday and
Friday. Follow up on
medical out patient
department on Monday or
Thursday.
7) DIVERSIONAL THERAPY USED FOR CLIENT
Diversional therapies are used to divert one’s thoughts from life stresses or to fill time.
I have used the following aspects of diversional therapy to overcome his situation.
 Physical therapy: deep breathing and coughing exercise was
encouraged to perform. Proper position of the patient was maintained so that she can feel relaxed
and comfortable.
 Group therapy: I gave many examples of other people having the same disease condition and
also introduced him with some of them so that he can realize that many others have and share
problems which are very similar to their own problems and that they are not alone in their
suffering.
 Relaxation training: I encouraged my patient for performing yoga and meditation as relaxation
produces physiological effect that are opposite to those anxiety, that is slow heart rate, increased
peripheral blood flow.
 Psychological therapy: I encourage my patient to express his feelings and attitude, and
communicate with the care takers as well as the family members. Because of this his
psychological depression can be reduced and he feels better.
27

 Medicine therapy: I provided his medicine to relieve his pain and for his
better recovery.
 Recreational therapy: according to this therapy, I encouraged my patient to
listen songs of his choice. I also encouraged him to sing songs as he loves to listen and sing old
melody filmy songs songs. Beside these I also encouraged my patient to read magazines,
newspaper, listen radio, etc. so that it would help patient diverse his mind away from his anxiety
and depression.
APPLICATION OF NURSING THEORIES
Virginia Henderson’s Independent Theory:
In 1955, Henderson formulated unique function of nursing, she purposed 14
components of Basic nursing care. The components are as follows:
 Breathe normally.
 Eat and drink adequately
 Eliminate body wastes
 Move and maintain desirable postures.
 Sleep and rest
 Select suitable clothes- dress and undress
 Maintain body temperature within normal range by adjusting clothing and modifying the
environment.
 Keep the body clean and well groomed and protect the integument.
 Avoid danger in the environment and avoid injuring others.
 Communicate with others in expressing emotions, needs, fear or opinion.
 Worship according to one’s faith.
 Play or participate in various forms of recreation.
 Learn, discover or satisfy the curiosity that leads to normal developmental and health and
use of the available facilities.
28

APPLICATION OF THEORY ON MY PATIENT
 Breath normally:- I encourage my patient to do deep breathing and coughing
exercise. This helps to promote lung expansion and gases extent and also help to
loosen and bring out secretion.
 Eat and drink adequately:- I encourage my patient to eat and drink adequately
according to body needs and the patient food habit was well maintained.he was
prescribed to have fluid less than 500ml/day
 Eliminate body waste:- My patient bowel and bladder habit was normal so his
eliminate body waste pattern was well maintained.
 Move and maintain desirable posture:- I helped my patient to move and maintain
the desirable position
 Sleep and rest: I encouraged patient to take a adequate rest and sleep according to
body need and disease condition for a positive health.
 Select suitable clothe and dress:- Suitable clothe was selected.
 Body cleanliness:- I encourage my patient to keep her body clean.
29

 Avoid danger in the environment and avoid injuring others: sometimes my patient
shows aggressive behavior so antipsychotics drugs were prescribed to my patient
to avoid danger in the environment and also to avoid injuring others.
 Communicate with others in expressing emotions, needs, fear or opinion:- As my
patient was able to communicate, his communication pattern was maintaining.
 Worship according to one’s faith
 Play or participate in various forms of recreation:- This component help me
inspire my patient to write new poems, story and jokes.
9) NURSING CARE PLAN
30

31
ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATI
ON
RATIONAL EVALUATI
ON
Subjective data:
patient says
that, “my hands
and face are
swelling”
objective data:
patient’s face
and hand was
swelling
Excess fluid
volume
related to
fluid
accumulatio
n between
dialysis
treatments.
Patient
will
maintai
n fluid
volume
status
within
establis
hed
paramet
ers.
-assess weight,
lung sounds and
extremities for
presence of
edema
-monitor intake
and output.
Some patient
continue to
urinate small
amounts, but it
is inadequate to
clear all waste
products.
-monitor
laboratory data:
blood
urea,nitrogen,ser
um
creatinine,sodiu
m,potassium,cal
cium,hb,etc
-teach pt the
need for
maintaining
fluid restrictions
between
treatment
-teach pt the
need for
restricting
sodium intake
-weight, lung
sounds and
extremities was
assessed for
presence of
edema.
-input and
output was
monitored.
-laboratory data
was monitored
-fluid
restrictions
between
treatment was
maintained.
-the need for
restricting
sodium intake
was teached.
-To determine the
fluid volume so that
treatment
parameters can be
identified.
-Intake is limited
and must be
monitored to
prevent fluid
volume overload.
-nitrogenous waste
and electrolytes
accumulate
between treatments.
Anemia and blood
losses associated
with hemodialysis
are complications
associated with
kidney failure.
-to prevent excess
intake, which can
lead to
hypervolemia
-sodium intake
stimulates thirst
which can lead to
excessive fluid
intake and
subsequent
hypervolemia.
My goal
was fully
met as
patient is
free of
peripheral
edema.

32
ON
RATIONAL EVALUATI
ON
Subjective data:
patient says
that, “my hand
and face are
swelling”
objective data:
patient’s hand
and face was
swelling
Risk for
skin
integrity
related to
alterations
in skin
turgor
(edema)
Patient
will
maintai
n an
intact
skin
-inspect skin
for changes in
colour,turgor,va
scularity,note
redness
-monitor fluid
intake and
hydration of
skin and
mucous
membranes
-inspect
dependent areas
for edema.
Elevate legs as
indicated.
- provide
soothing skin
care. Restrict
use of soaps.
Apply ointments
or creams.
-keep linens dry,
wrinkles free
-investigate
reports of
itching
- suggest
wearing loose
fitting cotton
garments
-skin was
inspect for
changes in
colour, turgor,
vasclarity.
- fluid intake
and hydration of
skin and mucous
membranes was
monitored.
-dependent areas
for edema was
inspected and
legs was
elevated as
indicated.
-soothing skin
care was
provided and
creams,
ointments was
applied.
-linens were
kept dry and
wrinkles free.
- reports of
itching was
investigated
- loose fitting
cotton garments
were suggested
to wear.
-indicates areas of
poor
circulation/breakdo
wn that may lead to
infection.
-detects presence of
dehydration or
overhydration that
affect circulation
and tissue integrity
at the cellular level.
-edematous tissues
are prone to
breakdown.
Elevation promotes
venous return,
limiting venous
stasis,edema
formation.
-lotions and
ointment may be
desired to relieve
dry,cracked skin.
-reduces dermal
irritation and risk of
skin breakdown.
-although dialysis
has largely
eliminated skin
problems associated
with uremic
frost,itching can
occur because the
skin is an excretory
route for waste
products.
-prevents direct
dermal irritation
and promotes
evaporation of
moisture on the
skin.
My goal
was fully
met as
patient
maintain
an intact
skin.
ON
RATIONAL EVALUATI
ON
Subjective data:
patient says
that, “I have
itching in my
neck”
objective data:
patient’s neck
was red.
Risk for
injury
related to
infection
Patient
will be
free of
infectio
n
-assess skin ,
nothing
redness,swelling
,local
warmth,tendern
ess
-avoid
contamination
of assess site.
-nothing
redness,local
warmth,tenderne
ss and skin was
assessed
-Aseptic
technique and
masks were
-signs of local
infection, which
can progress to
sepsis if untreated
-prevents
introduction of
organisms that can
My goal
was fully
met as
patient did
not
develop
any sign
of
infection

34
ON
RATIONAL EVALUATI
ON
Subjective data:
patient says
that, “I can’t do
anything, I am
useless”
objective data:
patient looks
depressed
Situational
low self
esteem
related to
chronic
kidney
failure
requiring
machine
dependency
Patient
will
mainati
n
positive
body
image
- monitor
patients
response to
illness and
treatments
-allow patient to
grieve over his
losses
-acknowledge
patients grief
about being
dependent on a
machine
-support
strengths,self
confidence,deter
mination and
motivation to
live
-help pt to
develop or
continue
interests beyond
dialysis and
return to as near
normal life as
possible
-monitor for
excessive
concerns about
losses,depressio
n
-patients
response to
illness and
treatments were
monitored.
-patient was
allowed to
grieve over his
losses
-patient grief
about being
dependent on a
machine was
acknowledged
-strengths,self
confidence,
determination
and motivation
to live was
supported.
-pt was helped
to develop
interest beyond
dialysis and
return to as near
normal life as
possible
-excessive
concerns about
losses,
depression was
monitored
-to determine the
effect of health
status changes so
that appropriate
interventions can be
planned
-grieving is a
necessary part of
recovery
-demonstrate
empathy and
validates the
patients feeling
-Patients
undergoing dialysis
are not disabled in
all aspects of life.
Many live nearly
normal lives while
maintaining
treatment schedule
-pt may tend to
withdraw from
social activities
because of their
new schedule and
feelings of
loss,focusing on
other interests will
help the pt place
less focus on his
dependency
-there may be
indications of
suicidal
ideation,which
needs to be
identified and
treated quickly
My goal
was fully
met as
patient
verbalizes
acceptance
of
treatment
regimen as
part of
lifestyle
ON
RATIONAL EVALUATI
ON
Subjective data:
patient says
that, “I can’t do
anything, I am
useless”
objective data:
patient looks
depressed
Disturbed
thought
processes
related to
accumulatio
n of toxins
Patient
will
mainati
n
optimal
level of
mentati
on
- assess extent
of impairment
in thinking
ability, memory
and orientation
-provide
quiet/calm
environment
- impairment in
thinking ability,
memory and
orientation was
assessed
-quiet/calm
environment
was provided
-uremic syndrome’s
effect can begin
with minor
confusion,
irritability
-minimizes
environmental
stimuli and reduces
confusion
My goal
was fully
met as
patient

DISCHARGE TEACHING:-
Categories Plan Rationale
Medication
• Instruct patient to take prescribed
medications regularly and comply with
the treatment regimen prescribed by the
physician.
• Teach patient regarding the names of
the drug, its dosage, time of
administration, its contraindication and
side effects.
• Inform patient and significant others not
to take drugs not prescribed by the
physician.
• Instruct the patient to check for the
expiration date of the drug before taking
it.
• Do not administer any other drug with
same action without the physician’s
prescription.
• Educate the patient and the significant
others about the expected responses of
drug to the body, side effects, adverse
effects that may possibly seen into the
patient.
• Instruct the significant others to report
any remarkable adverse reactions or
any appearance of side effects noted.
-Compliance to appropriate
medication and treatment
prevents further complications
and resistance to antibiotics and
promote continuous recovery of
optimal health.
-The patient has the right to know
his drug’s therapeutic effects as
well as its adverse effects. He
also has the right to gain
awareness about why is it given
to him.
-Drug interactions may occur
which may be fatal to patient’s
current situation.
-Checking for the expiration date
of the drug before administering it
ensures it potency and safety. It
also prevents any unwanted
reactions like hypersensitivity.
-Non-prescription drug may have
antagonistic or synergistic effects
if taken with other drugs.
-To be geared up of enough
information that may lead to
immediate medical responses.
-For immediate remedial action
response and to prevent any
complicated reactions.
35

Exercise • Explain to patient the significance of
regular exercise like walking and
stretching. If unable to mobilize alone,
instruct the watcher to give assistance
all the time. Encourage to use crutches
or any device for support. Stretching
upper extremities also promote healthy
living. Also instruct patient to perform
passive range of motion.
• Teach patient to wait for 1 to 2 hours
after eating before performing any
physical activities.
Instruct the patient to practice deep
breathing exercise.
-Exercises promote proper blood
circulation and prevent arterial and
venous stasis thus lessens platelet
coagulation to aged people. Older
people have weakened blood
vessel walls which can cause any
alteration in blood flow.
Also exercise prevents atrophy of
the muscles.
-Older people has slower digestion
rate, thus they need to conserve
more oxygen which will be
necessary for digestion of food.
Activities must be limited to
decrease oxygen demand by
organs and tissues other than the
digestive system.
-Deep breathing exercises promote
thoracic expansion which allows air
to enter the respiratory tract and
provide oxygen to the alveoli to
avoid atelectasis or lung collapse
due to increase fluid pressure in
the pleural space.
Treatment • Instruct patient to comply with his
medication treatment like the continuous
use of beta blocker Metoprolol for
control of hypertension and Insulin for
diabetes mellitus.
• Instruct client to seek medical help if any
unusualties are felt such as tingling
sensation or paresthesia, fatigue and
body malaise, dizziness, headaches,
irritability, tremors, diaphoresis, etc.
• As part of long-time treatment, advise
-Maintenance meds should not be
forgotten to achieve highest
therapeutic effect.
-These unusualties may be
indicative of worsening condition.
-Medical alert bracelet provides
36

patient to wear medical alert bracelet all
the time and wherever he goes. It
contains the patient’s name, disease
condition, address and contact person.
• Advise to have a family member take
your blood pressure to check if you’re
maintaining a stable blood pressure.
• Since the client has his own glucose
monitor, tell client to continue monitoring
blood glucose level, and immediately
seek for medical help if level is
abnormally high.
basic information about the client in
case of accidents.
-Monitor of blood pressure is
significant for evaluating the
medication’s effectiveness.
-Glucose monitoring is a big factor
in the management of diabetes
mellitus.
Hygiene • Instruct patient to practice foot care to
prevent ulceration and formation of
gangrenous tissues to the lower
extremities.
- Check and carefully wash your feet
every day.
-Do not wear shoes that are too small or
socks that do not fit right inside your
shoes.
-Soak your feet in warm soapy water for
10 minutes before cutting your nails.
Trim your toenails straight across to
prevent ingrown toenails. You may also
file down your toenails. Do not cut your
nails into the corners or close to the skin.
You should not dig under or around the
nail.
• Emphasize the importance of bathing
everyday. Wash genitals with mild soap.
-Proper foot care prevents injury to
feet and toes.
-Proper bathing eliminates
proliferation of germs and bacteria
in the body. Mild soap does not
irritate the skin and the genitals.
37

• Instruct client to maintain good oral
hygiene.
• Instruct to wear clean clothes and
underwear.
-Tooth brushing prevents build up
of plaques and cavities.
-Dirty or improperly washed
underwear may become a
sanctuary for microbial growth.
Microbes may enter the genitals
and might worsen the client’s
UTI/Cystitis.
Out-Patient
Referral
• Encourage patient to undergo physical
therapy sessions.
-A Physical Therapist is a source of
information to understand age-
related changes and offer
assistance for regaining lost
abilities or develop new ones.
Physical therapy can be applied to
the client’s condition: arthritis,
urinary and fecal incontinence,
amputation, and cardiac and
pulmonary disorders. It can :
a). increase, restore or maintain
range of motion, physical strength,
flexibility, coordination, balance
and endurance
b.) aids adaptations to make the
home accessible and safe
teach positioning, transfers, and
walking skills
c.) promote maximum function and
independence within an individual's
capability
d.) increase overall fitness through
exercise programs
e.) prevent further decline in
functional abilities through
education, energy conservation
techniques, joint protection, and
use of assistive devices to promote
independence
38

• Advise to have check-ups after discharge.
• Advise to have regular laboratory exams
for creatinine, albumin, sodium,
potassium and calcium.
• Encourage to undergo ABG Test every
month or once every 2 months.
f.) improve sensation, joint
proprioception
g.) reduce pain
-Serves as an evaluation process
to note if condition has progressed
to better or worse.
-To assess for renal function.
Diet • Instruct client to avoid simple sugars.
Take energy from complex carbohydrates
like unpolished rice, bread and
vegetables.
• Encourage patient to eat fibrous foods
like fruits and vegetables. But do not eat
too much as it can irritate the GI tract and
causes bleeding. Other examples of
sources of fiber are: whole grains, cereals
and legumes.
• Limit intake of purine rich foods such as
liver, beef kidneys, brains and meat
extracts. Encourage to eat in moderate
amount: asparagus, cauliflower, spinach,
mushrooms, green peas, dried peas and
beans.
-Simple sugars easily break down
and enter the blood stream.
Complex carbohydrates can
sustain the body’s energy
requirement for a longer time
because they are not broken down
easily.
-A diet rich in fiber relieves
constipation. It adds bulk to the
excreta and facilities expulsion.
-Accumulation of uric acid in the
joints causes arthritis. Uric acid is
the by product of purine break
down in the liver. Because of renal
malfunction, uric acid is retained in
the blood stream and is shunted to
connective tissues.
WHAT I LEARNED FROM THIS CASE STUDY:-
Case study is the comprehensive study of one selected patient and comparative study with books. During
my case study, I learned the following things.
39

i. About the disease:-
I got opportunity to read and gain comprehensive knowledge through various books, literatures,
teachers, doctors, ward staffs, colleagues and via. Secondary internet. I also obtained a comprehensive
knowledge on the disease its treatment and management.
ii. About the patient:-
My patient was a open book to learn for me, as I got an opportunity in learning through
involving patients care, treatment, diversional therapy and teaching not only from patient but also from
his family member. I learned personal quality of patient and use the information in treating her. I also
taught the families, socio cultural, economical, religious and traditional beliefs of the patient which
influence her health.
iii. About nursing care:-
I applied holistic approach while giving nursing care to the patient. I followed the theorie of
Henderson in providing nursing care and I gained more knowledge and skill.
iv. About documentation.
12) CONCLUSIONS AND SUMMARY OF CASE STUDY
My patient name is mr. laxman pandit , 68yrs old, male with the diagnosis of Chronic kidney
disease.
40

Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal
function over a period of months or years
 Heredity
 Glomerular dysfunction
 Diabetic nephropathy
 Hypertension
 Glomerulonephritis
 Polycystic kidney disease
 Urinary tract obstruction
 Bladder tumour
 Urethral obstruction
 Hypertensive nephrosclerosis (hardening of the kidney) are some of the causes of chronic kidney
disease
The clinical features of ESRD are: weakness and fatigue, confusion, seizures, burning soles of
feet, thin, brittle nails, hypertension,periorbital oedema,etc
It can be investigate through laboratory test such as cbc, urinalysis, blood urea ,ultrasonography,
kub film etc.
During my case study, I provided health education, applied different diversional measures, treatment,
investigation, diet, personnel hygiene etc. I feel great pleasure whenever patient and his family get
treatment satisfaction and getting better. His general condition was improved so he was discharged.
13) REFERENCES
41

 Nursing care plan, Marilynn E. Doengs, Mary. Francesmoorhoose, Alice C. Geissles. Murs 6th
edition
 Rai lalita “nursing concept theories and principles”; 1st
edition
 Helth learning materials centre Tu, institute of medicine, maharajgunj, ktm, textbook of adult
helath nursing
 Mosby’s nursing drug reference,2007
 Phipps Monahan and sands marek neighbors”medical surgical nursing health and illness
perspectives” 7th
edition, page 1260 to 1271
 A Lippincott manual ”the Washington manual of medical therapeutics”,33rd
edition, page 430 to
433
 http://www.emedicinehealth.com/chronic_kidney_disease/page2_em.htm
 http://www.ehttp://www.emedicinehealth.com/chronic_kidney_disease/page4_em.htmmedicineh
ealth.com/chronic_kidney_disease/article_em.htm
 http://en.wikipedia.org/wiki/Chronic_kidney_disease
42

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