I.

INTRODUCTION

Case Scenario

Patient J.R…, a 45-year old female, as diagnose of ESRD 1 year ago and is admiited to the
hemodialysis unit since August 2022 with a chief complaint of shortness of breath and 1 day
prior to admission pt experience SOB, nausea, and chest tightness. Few hours prior to
admission symptoms persist have admitted. The patient has a Left AV fistula in the arm with a
strong bruit/thrill. The patient has a high creatinine result in level of 936 umol/L and is
hypertensive with an average of 150/90.

Past Medical History

 The patient as diagnosed with hypertension in the of age 37 y/o.

Personal and Social History

 The patient has a personal/ social history of cigarette smoking.

Pertinent Family History

 The patient has a family history of hypertention and kidney stones.

Immunization

 Hepa B vaccine received

Allergy

 Tha patient has a skin allergy.

II. OBJECTIVES

GENERAL OBJECTIVES:

 The case presentation seeks to demonstrate the student’s knowledge regarding a patient’s
general health and disease condition of a patient with diagnosis, its disease process,
possible complications, treatment plan, and medical and nursing intervention.
SPECIFIC OBJECTIVES:

 The students will be able to understand the patient’s description and disease process
 The student will learn about the treatment and surgical procedures for the disease.
 The student will efficiently provide an appropriate and proper nursing diagnosis for the
client’s medical condition and skillfully formulate nursing care plan for the identified
problems.

III. OVERVIEW OF ANATOMY & PHYSIOLOGY

THE RENAL SYSTEM

 The renal system, also known as the urinary system is made up of the kidneys, ureters,
bladder and urethra. The kidneys, a pair of organs located in the back of abdominal cavity
which is responsible in filtering waste products from the blood in the form of urine. The
urine passes down through the ureters, which are muscular tubes connecting the kidneys
to the bladder. The bladder is a muscular sac that stores urine until it increases the
pressure on its wall and triggers the micturition reflex. This allows the urine to flow
through the urethra and out of the body.
 Kidneys- it is responsible in receiving blood from the heart and filters the blood via the
nephrons (glomerulus) and is responsible in the regulation of water excretion, electrolyte
excretion, acidbase balance, auto-regulation of blood pressure, renal clearance, regulation
of red blood cell, vitamin D synthesis, erythropoietin production.
 Glomerulus- is a part of nephron which creates a filtrate/urine that will progress through
the rest of the nephron( renal tubule)
 Renal Tubule- it adjusts the filtrate by pulling out water and ions. Then the substances
leftover will be excreted in the urine.

V. DESCRIPTIONS OF THE DISEASE

 End-stage renal failure, also known as end-stage renal disease (ESRD), occurs when
kidney function has decreased to the point where the kidneys are no longer able to
function independently. Dialysis or a kidney transplant are the only ways an end-stage
renal failure patient can live more than a few weeks.
 Chronic hypertension affects tubulointerstitial tissues, glomeruli, and and small blood
vessels, leading to hypertensive nephrosclerosis. Progressive chronic renal disease
therefore arises. Poorly controlled hypertension leads to gradual renal damage, which is
known as hypertensive nephrosclerosis. Anorexia, nausea, vomiting, pruritus,
somnolence, or disorientation are examples of symptoms and indicators of chronic kidney
disease. indicators of end-organ damage due to hypertension may also manifest.

V. PATHOPHYSIOLOGY


Precipitating Factors:
 Hypertension Predisposing factor
 Increase sodium & protein
 Female
intake
 Unhealthy foods ( junk foods)
 






KIDNEY INJURY

VASCULATURE GLOMERULUS TUBULE INTERSTITIUM

Endothelial dysfunction Glomerular hypertention Tubular damage Inflammation
Endothelial cell Damage Glomerular cell hypertrophy Tubular cell Injury Oxidative stress

Chronic Kidney Disease

Progression

Arteriolar Sclerosis Glomerulosclerosis Tubular Atrophy Intertitial

Fibrosis

END STAGE RENAL DISEASE

 A. ETIOLOGY

Chronic hypertension can cause hypertensive nephrosclerosis, resulting in chronic kidney disease
and, infrequently, end-stage renal disease .Hypertensive nephrosclerosis is one of the most
common diagnoses in individuals with end-stage renal disease, because of the prevalence of
persistent hypertension and hypertensive nephrosclerosis. Risk factors include:

Book Picture Patient’s Picture

Non Modifiable Factors Non Modifiable Factors

 Hereditary  Hereditary
 Age
 Race
Modifiable factors Modifiable factors

 Diabetic nephropathy  Hypertention

 Poorly controlled moderate to  Smoking
severe hypertension  Unhealthy diets and habits
 Smoking
 Unhealthy diets and habits

B. Disease Process

The most common cause of secondary hypertension is chronic kidney disease (CKD), which is
also the world's leading cause of death. Hypertension is thought to be a significant co-morbid
factor associated with CKD and affects 80–85% of patients with CKD, with more severe
glomerular diseases having a higher incidence of hypertension. The elevation of systemic blood
pressure (BP) for any given cause of chronic kidney disease (CKD), including hypertension
itself, accentuates the rate at which glomerular filtration rate (GFR) declines. This makes
hypertension an independent risk factor for end-stage renal disease. CKD frequently advances
over time and has 5 stages based on how efficiently your kidneys are currently able to filter your
blood. Your kidneys' function is measured by your glomerular filtration rate (GFR).
 Stage 1 of Chronic Kidney Disease (CKD)

-GFR above 90 mL/min:

Stage 2 of Chronic Kidney Disease (CKD)

-GFR 60-89 mL/min

Stage 3 of Chronic Kidney Disease (CKD)

-GFR: 30-59 mL/min

Stage 4 of Chronic Kidney Disease (CKD)
-GFR: 15-29 mL/min
Stage 5 of Chronic Kidney Disease (CKD)
-GFR less than 15: Your kidneys have failed and have stop
doing their job to filter waist from the blood

C. Manifestations/signs and symptoms

Clinical manifestations of the client that are related to her case End Stage Renal Disease
Secondary to Hypertensive Nephorsclerosis includes:

 Shortness of breath
 Nausea
 Difficulty of sleeping
 Itchy skin and darkened skin
 Headaches
 Chest tightness
VI. LABORATORY AND DIAGNOSTIC TEST
A. Laboratory Test
 Creatinine: it is the test which measures how well the kidneys are functioning or
performing their job in filtering waste from the blood.
 Blood Urea Nitrogen (BUN): this test measures the amount of urea nitrogen in the
blood. Urea
  nitrogen is a waste product that the kidneys remove from the blood.
 Complete Blood Count (CBC): it indicates the counts of white blood cells, red blood
cells, and
 and platelet count , the concentration of hemoglobin and hematocrit.

Test January November Reference Range

Hgb 91 122 137.00-175.00

Hct 0.28 0.36 0.400-0.510

WBC 8.0 7.13 4.23- 9.07

Lymphocyte 0.24 0.22 22.00-53.00

Eosinophil 0.04 0.03 1.00-7.00

Monocyte 0.09 0.09 5.00-12.00

Platelet 175 207 150.00-450.00

Creatinine 936 1177.5 59.00-104.00

anti-HBs or HBsAb (Hepatitis B surface antibody) - A "positive" or "reactive" anti-HBs (or

HBsAb) test result indicates that a person is protected against the hepatitis B virus. This
protection can be the result of receiving the hepatitis B vaccine or successfully recovering from a
past hepatitis B infection. This test is not routinely included in blood bank screenings. A positive
anti-HBs (or HBsAb) test result means you are “immune” and protected against the hepatitis B
virus and cannot be infected. You are not infected and cannot spread hepatitis B to others.
 Patient Result: 490.20 MIU/ML

NORMAL VALUE: NONREACTIVE: <10 MIU/ML

REACTIVE :>10 MIU/ML

B. Diagnostic test

2D Echo Report: It is a diagnostic test that uses ultrasound waves to assess the functioning of
the heart and it allows structures to be viewed moving in real time in a cross-section of the heart.

Normal left ventricular dimension with normal all motion and contractility
Normal relative all thickness and mass index
The ejection fraction is normal at 56% by Simpson’s
Normal sized left atrium
Normal sized right atrium and right ventricle ith normal contractility
Atherosclerotic aortic root but no aneurysm noted

Trivial mitral and tricuspid regurgitation

Structurally normal pulmonic valve and aortic valve with no stenosis nor regurgitation noted

No intracardiac thrombus nor effusion noted

No shunt demonstrated
Normal pulmonary artery pressure

VII. MEDICAL MANAGEMENT/ SURGICAL MANAGEMENT

VII. SURGICAL MANAGEMENT

ARTERIOVENOUS (AV) FISTULA

 : It is a surgical connection that’s made between an artery and a vein for dialysis/ vascular
access. It plays a key role in the management of kidney failure patient requiring hemodialysis.

 PRE-OP Management

:It is essential to obtain consent first for the procedure

:Discuss the risks, benefits and potential complications of the procedure

 INTRA-OP Management

:The patient should be position in a supine position with the corresponding arm outstretched to
90 degrees, prepped, and draped in a usual sterile fashion.

:Principles of arteriovenous fistula creation include obtaining vessel control proximally and
distally, and the anastomosis should be made without tension or kinking.

 POST-OP Management

: Check fistula if working: Check for bruit sound/Thrill

:Advise that the dressing stay dry for atleast three days before being change

: Do not take blood pressure measurements from fistula arm

: Advise the patient to avoid sleeping on the fistula arm

VIII .NURSING CARE PLAN

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

PROBLEM: STG Independent Nursing Independent NI: STG:
“inistop kong After an hour of Intervention Instruct patients that After an hour of
inumin yung nursing Instruct the patient on simple changes such nursing intervention
lifestyle
maintenance ko kaya intervention the as exercise, quitting the patient
modifications.
natriggered yung patient will smoking, and adhering verbalized
Allow inquiries about
kidney ko” as verbalize to their medication understanding of
dialysis and kidney
verbalized by the understanding of transplant. regimen can preserve ESRD, its
patient ESRD, its kidney function. symptoms, and its
Instruct on appropriate
Subjective Data symptoms, and its diets. management.
 Shortness of management. Dialysis and kidney
Have the patient
breath LTG verbalize symptoms of transplants require LTG:
concern.
 Nausea After 1 week of life-long maintenance, After 1 week of
 Headache nursing Educate on fistula and support from nursing intervention
care.
 Chest intervention the nurses can enhance the patient adhere to
tightness patient will adhere adherence. the treatment plan as
Objective Data: to the treatment evidenced by lab
Dependent Nursing
 Weight: plan as evidenced Intervention Adhering to a kidney- values within the
1. Administered
Pre:58.5 kg by lab values Friendly diet can be expected ranges.
medication as
Dry:56.5 kg within the expected ordered difficult. The patient
Post:56 kg ranges. may need to limit salt,
 BP: 150/80 potassium, and fluids.
 HR: 80 Provide easy-to-
Collaborative
 RR:19 Management : understand written
1. Patient’s
Nursing diagnosis instructions on foods
referral to
Deficient knowledge dietician/ the patient should
nutrtionist
Related to limit.
Misinformation Teach the patient
about ESRD and its about the signs of
management as developing
evidenced by complications from
Inaccurate follow- ESRD. Dyspnea,
through of confusion, changes in
instructions urination, weight gain,
high blood pressure,
and muscle cramps
require immediate
assessment.

A fistula is created to
allow for vascular
access with dialysis.
Complications such as
infection or bleeding
can occur as it heals.
Instruct on proper care
and when to alert the
healthcare provider if
concerns arise

Dependent NI:
1. To prompt
treatment
Collaborative
management :
1. To optimize
the patient’s
oral intake,
providing
suitable oral
nutrition
supplements
and possible
administration
 of enteral and
parenteral
nutrtion.

IX. EVALUATION & DISCHARGE PLANNING

The following medications are used in continuation in line with the treatment
Medication compliance - Antihypertensives for the treatment of hypertension should be taken everyday
- Take Isordil as needed for (+) chest pain
- ROM exercise should be advise to the patient for thegood blood flow
Exercise and activity circulation
- Avoid any activities that may affect or put pressure in the fistula arm.
- Explain to patient about controlling and maintaining blood pressure and CKD
Health Teachings progression
- Instruct on supplements as prescribed.
- Avoid smoking
Diet and Nutrition - DASH diet should be advise to the patient
- limit foods high in potassium, sodium, and phosphorus.
- Encourage the patient to spend a time of silence in a day for a moment of
Spiritually prayer to strengthen faith in God.